Payment Integrity Analyst III (ALD)

Job Summary

The Payment Integrity Analyst III is responsible for leading or assisting in vendor implementations and configuration, algorithm/edit customizations, overpayment remediation, as well as other Payment Integrity functions. The position is also responsible for supporting Payment Integrity solutions focused on trending overpayment and refund reasons to identify and fully develop pipeline of new Payment Integrity initiatives.  These initiatives include additional overpayment project pipeline as well as development of cost avoidance practices. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.

Duties

Serves as vendor oversight monitoring to ensure proper submission of files and correct invoicing as well as monitoring QA metrics to meet all vendor estimates. Serves as SME for all Payment Integrity functions to include both Retrospective Data Mining as well as Pre-Payment cost avoidance.

Supports the creation and execution of strategies that determine impact of opportunity and recover overpayments as well as prospective internal controls preventing future overpayments of each applicable pipeline opportunity. Works with both internal and external groups to define and develop cost avoidance measures to ensure continued success.

Fields and responds to escalated requests (including research) for all inquiries both internal and external; Fields and responds to Provider Dispute Resolution (PDR) requests stemming from Payment Integrity activities; supports correspondence in identification of trends for overpayment opportunities resulting in future pipeline activity.

Identifies and defines Payment Integrity issues and reviews and analyzes evidence, utilizes data for the purpose of verifying errors and identifying systemic errors, works as an active team member during scheduled engagements and work collaboratively to achieve the goals of the team, and provides feedback to the team lead on any issues identified during research or claims review.

Serves as a subject matter expert and leads and/or assists in algorithm/edit customizations, as well as all vendor implementations as needed. Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.

Performs other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:

At least 3 years of experience in Cost Avoidance and/or Coordination of Benefits or in Payment Integrity.

At least 5 years participating in healthcare (Medicare, Medicaid, Commercial).

At least 5 years of experience with health care data.

Experience in project implementation.

Skills

Required:
Knowledge in CPT, HCPCS, ICD-9, ICD-10, Medicare, and Medicaid rules and regulations.

Working knowledge of claims coding and medical terminology. Solid understanding of standard claims processing systems and claims data analysis.

Strong project leadership and management skills required; ability to prioritize, plan, and handle multiple tasks/demands simultaneously.

Expert knowledge of healthcare reimbursement concepts.

Excellent interpersonal, verbal, and written communication skills required with excellent analytical and problem-solving skills.

Must be collaborative ability to establish credibility quickly with all levels of management across multiple functional areas.

Must be able to present findings across all departments.

Must be familiar with coordinating benefits between health plan payers.

Advanced knowledge of Microsoft Office suite, including Word, Excel and PowerPoint.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information