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Payment Integrity Analyst II

Job Category:  Administrative, HR, Business Professionals
Department:  Payment Integrity
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  5731

 

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

Job Summary

The Payment Integrity Analyst II is responsible for performing Payment Integrity activities to include validation of findings: and the identification, development, completion of a pipeline of new Payment Integrity initiatives to drive incremental savings for the organization. This position would additionally provide support in tracking pipeline project status and Payment Integrity cost avoidance development.

Duties

Analyze and validate findings for approved scenarios, from both internal and external sources, to the standards of Quality Assurance and timeliness within the department. Analyze findings to create and execute strategies that determine the global impact of the opportunity and recover overpayments of each opportunity. Tracks all recoveries by opportunity. Performs all follow up functions including overseeing remediation reporting and end project QA analysis as needed.

 

Analyze incoming internal and external correspondence to determine additional needs; review, research and resolve inquiries; and, track all submissions to ensure all inquiries are resolved and department metrics are met.

 

Analyze correspondence to identify strategies that determine future pipeline opportunities. Support team efforts in leading concepts/projects to completion/implementation, and perform necessary research of governmental regulatory agencies for reference as needed.

 

Support the manager and senior analysts in developing and implementing prospective internal controls preventing future overpayments of each pipeline opportunity.

 

Perform other duties as assigned.

Education Required
Associate's Degree
In lieu of degree, equivalent education and/or experience may be considered.
Education Preferred
Bachelor's Degree
Experience

Required:
At least 4 years of healthcare (Medicare, Medicaid, Commercial) Payment Integrity or program integrity experience.

 

Experienced in interpreting complex contractual terms with Providers, Facilities, Plan Partners, delegated groups.

 

Experienced in working with Hospital and Provider Billing Departments.

Skills

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

 

Ability to prioritize, plan, and handle multiple tasks/demands simultaneously.

 

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

 

Understanding of standard claims processing systems and claims data analysis.

 

Working knowledge of claims coding and medical terminology.

 

Solid understanding of standard claims processing systems and claims data analysis.

 

Good knowledge of contractual pricing mechanisms for inpatient, outpatient, LTC and ancillary services.

 

Understanding of the application of Division of Financial Responsibility (Doffer) to claims processing.

 

Ability to operate PC-based software programs or automated database management systems.

Licenses/Certifications Required
Licenses/Certifications Preferred
Certified Professional Coder (CPC)
Certified Coding Specialist (CCS) designation by the American Health Information Management Association (AHIMA).
Required Training
Additional Information

 

L.A. Care offers a wide range of benefits including

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)