Senior Consultant

Job Title

HM Note: The client is specifically looking for resources with extensive Facets experience, particularly around DME claims and authorizations. Must Have's: 1. Experience implementing Medicare LOB on Facets platform 2. Knowledge of CMS regulatory guidelines/ policies and ability to relate that to Facets capability to administer those guidelines/ policies 3. Payment Integrity Should be able to work independently to review current Facets configuration and work with client stakeholders to provide recommendations Payment Operations and Payment Integrity Workstreams Implement a process to test end-to-end common Medicare Advantage leakage scenarios across multiple Medicare service categories to rapidly determine whether any common issues are relevant at Client NC. Provide recommendations on priority focus areas based on prior leakage experience. This assumes tiger teams will implement end-to-end fixes for authorization-to-claim matching and the lesser-of rules across all Medicare services. Examples include: 1. MOOP Accumulator Accuracy (Part C only) If the system triggers $0 prematurely, the plan absorbs avoidable medical cost. Test that MOOP applies only after the precise allowed in network Part A/B amounts are reached. 2. No Surprises Act (NSA) — Ensure Not Over Applying Protections NSA requires in network cost share only for certain emergency and facility based OON care. Over broad application causes the plan to pay unnecessarily high amounts. Validate correct identification of true NSA qualifying claims. 3. Hospice Carve Out Enforcement Hospice related care should shift to Medicare FFS. MA plans frequently overpay hospice related inpatient, DME, labs, or drugs. Test routing of claims during hospice election and unrelated services rules. 4. MSP (Medicare Secondary Payer) Primacy Enforcement A top source of preventable overpayment. Validate correct primacy for GHP, liability/no fault, workers comp, black lung, and injury related services. 5. Accurate Encounter Data for Risk Adjustment Revenue Missing or rejected encounters reduce RAF revenue and increase effective medical cost ratio. Validate 837I/837P end to end acceptance and error correction. 6. NCCI / MUE Edits Enforcement Missing NCCI edits = duplicate, unbundled, or medically unlikely payments. Ensure correct quarterly versioning and modifier logic. 7. Provider Contract Rate & Fee Schedule Accuracy Post Migration Incorrect rates = systematic overpayment. Validate DRG, APC, SNF per diem, home health per visit, therapy fee schedules, and carve outs. 8. Prior Authorization (PA) Enforcement & Denial Integrity Validate PA requirement checks, denial codes, retro PA, and overturned appeal flows. 9. Admit Date Payer Responsibility (Inpatient Stays) MA should not pay for inpatient stays where the beneficiary enrolled after admission or moved to hospice mid stay. 10. Home Health Cost Share & Coverage Rules HH utilization spikes after migration if edits or coverage rules malfunction. Test visit limits, OON logic, and cost share amounts tied to D SNP 2026 PPO constraints. 11. Inpatient Outlier, Transfers, & DRG Weight Calculation Improper DRG Configuration or missing transfer logic leads to massive overpayment. 12. ER vs Urgent Care vs Observation Status Accuracy Upcoding urgent care to ER creates large avoidable expense. Validate POS, revenue codes, and observation hours. NSA adds complexity for true emergencies. 13. Duplicate & Corrected Claim Management Plans lose millions annually on duplicate outpatient, professional, or inpatient corrected claims. Validate DCN/ICN matching, timely filing, and automated duplicate denial logic. 14. Coverage Policy Denials (NCD/LCD) Missing coverage rules lead to payment of non covered, experimental, or medically unnecessary services. 15. Emergency Stabilization vs Post Stabilization OON Billing Incorrectly paying OON post stabilization care as emergency inflates spend. NSA defines the emergency portion only. 16. Chiropractic, PT/OT/ST Visit Limits & Medical Necessity Therapy categories are high leakage areas. Validate annual limits, frequency edits, and NCCI bundling logic. 17. Radiation, Imaging, and Bundling Logic CT/MRI/PET are NCCI-heavy zones prone to overpayment if edits aren't firing. 18. Ambulance Transport Coverage & OON Rules Ground ambulance is not covered under NSA; improper OON approvals cause overpayment. Validate medical necessity, mileage, and emergency vs non emergency distinctions. 19. Telehealth Cost Share & Modality Controls Incorrectly paying telehealth as in person or failing to enforce modality codes (audio only vs audio visual) results in pricing leakage. 20. Further strengthen foundational Client NC processes to ensure Medicare claims payment accuracy across all Medicare-covered services going forward. 21. Define and govern a Source of Truth (SOT) process, including roles and accountabilities, for annual and quarterly updates to Configuration inputs that affect Medicare claims processing. 22. Establish a process to manage updates to NCDs, MLNs, and CMS claims policy changes. 23. Provide oversight and documentation of requirements to implement fixes that impact multiple service categories identified through initial end-to-end testing. 24. Lead, with SME expertise, the Client NC team in developing updated reimbursement policies aligned to industry standards and in executing pre-payment edits that minimize leakage. 25. Provide expertise on CMS requirements, including detailed knowledge of the Medicare claims processing manual, benefit policy manual, program integrity manual, Medicare managed care manual, CMS fee schedules, and coding guidelines, to support remediation of identified issues. 26. Partner with actuarial to quantify savings associated with implemented fixes, leveraging detailed knowledge of the remediation approach. End-To-End Workstream Collaborate with the team to establish rapid methods to identify current Configuration and payment leakage across key Medicare service categories, and define what is needed to remediate issues quickly across the inputs that support claims payment (medical policy, authorization, benefits, CMS rules, reimbursement policy, provider contracts, fee schedules etc.,) for the following: 1. SNF (Authorization-to-claims matching, HIPPS, PDPM/bundling, Therapies etc.,). 2. Surgery (inpatient, outpatient, and ASC payment accuracy and optimization (Global, Modifiers, Tolerance). 3. Part B drugs (Units, Wastage, Site, Modifiers). 4. DME (modifiers such as RR and NU; contract adherence). 5. Home health (S codes, HIPPS, per diem/PDGM, limits). 6. POS crosswalk to bill type/revenue code 7. Appropriate code to pay or deny requirements (i.e., Payment of Z codes with no associated C, D, or R code). Issue-Resolution Leadership and SME Support. Support the following: 1. Complete up-front end-to-end testing to identify leakage requiring remediation, and rapidly determine what is needed to implement fixes, including documentation, implementation, and validation testing. 2. Identify, oversee, and document requirements (including legacy deficiencies) to implement fixes that impact multiple service categories identified through initial end-to-end testing. 3. Oversee fixes and remediation timelines for claims processing, in collaboration with IT, to improve accuracy and prevent leakage. 4. Conduct end-to-end testing of fixes, with business review support, to ensure updates are accurate and validation is completed on time. 5. Provide expertise on the specific CMS requirements, including detailed knowledge of the Medicare Claims Processing Manual, Benefit Policy Manual, Program Integrity Manual, Medicare Managed Care Manual, CMS fee schedules, and coding guidelines, to support remediation of identified issues. 6. Partner with actuarial to quantify savings associated with implemented fixes, leveraging detailed knowledge of the remediation approach.