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Healthcare Regulatory And Compliance Specialist The candidate must have High School Diploma, Associates or College Degree, paralegal certification a plus. Should have 1+ year of healthcare compliance and regulatory experience. Must be proficient in the use of a personal computer, Excel and Word. Must have following qualifications and experience: Training or assisted with training of business leaders and employees on ethics, compliance, Federal Health Care Program requirements, State and Federal False Claims Acts, Anti-kickback Statutes and HIPAA; Researching Medicare, Medicaid and commercial managed care organization policies pertaining to billing requirements, coding and reimbursement; Communication skills to pursue network participation for MDL or GBG affiliated companies with managed care organizations; Completing and submitting applications for managed care provider agreements; Abstracting managed care provider agreements to summarize terms, plan descriptions and fee schedules for attorney review; Handling renewals, re-credentialing and amendments for existing managed care provider agreements; Preparing written reports on the status of participating managed care provider agreements; Monitoring reimbursement for accuracy; Identifying and reporting on types of claims denied and making recommendations to improve reimbursement; Researching and formulating grounds to appeal claim denials; Transmitting required documentation to government or commercial payers to resolve reimbursement issues.
Requisition Number : 18-0164.
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