The Payment Integrity Analyst is responsible for supporting the overall objectives of the Payment Integrity department. This role is responsible for executing a claim investigation and recovery strategy which includes the analysis of claims data for identifying cost containment opportunities across many different claims areas to ensure proper claims payments. Our Payment Integrity Analysts also work to review and analyze new audit concepts and recommendations for recoveries. They will partner with our fraud, waste and abuse team on additional recovery audits and investigations. They will coordinate with other CCA areas such as Clinical, Contracting and Provider Relations to ensure all our efforts are in sync. This role is integral in ensuring claim payment integrity as it supports all recovery efforts for CCA Claims processing. The Payment Integrity Analyst will report to the Manager of Payment Integrity and will support various operational functions. The role requires strong analytic skills as well as solid understanding of payment integrity/payment policy initiatives.
· Perform initial and ongoing analysis or review of existing state of payment integrity within CCA
· Work with the Payment Integrity Manager and Director on a strategic plan of action to begin implementation of new PI initiatives, best practices and reporting
· Maintain an ongoing library of payment integrity opportunities factoring overall risks, ROI and most efficient order to implement changes
· Partner with Sr Claims auditor and others on the Payment Integrity or Claims team to ensure collaboration, communication and knowledge sharing to maximize team efforts and efficiency
· Collaborate with PCG, other CCA departments as well as providers as needed to ensure prompt and appropriate action is taken regarding cost avoidance/cost containment activities
· Investigate potential claim payment inaccuracies, using best practices, known industry standards or potential erroneous system coding changes/updates
· Perform or oversee various payment integrity audits or validations including; Contract Reviews, Benefit Configuration, Mandate adherence
· Oversee claims audit vendor activities for accuracy, adherence to scope, claim recovery activities, invoicing, new concepts submission and claim sample approval
· Monitor vendor claim files or create internal claim ad hoc and template queries checking for opportunities for savings, payment inaccuracy and contract adherence
· Interact with claims payment vendor, claims audit vendor or other internal departments to discuss system corrections, audit recommendations and issues regarding claim overpayments and/or business decisions
· Work with appropriate staff to perform contract Audits or review to determine accuracy and validity of claims systems compared to agreements
Investigate, recover and resolve various types of claim inaccuracies and ensure appropriate gaps in processing are addressed
Bachelor’s Degree or equivalent business experience
Certified Coder a definite plus
3+ years Payment Integrity analysis experience
3+ years experience healthcare payor experience
· Understanding of Dual Eligibility, Medicare, Medicaid and Mass Health.
· Knowledge of CPT, ICD10, HCPCS or other coding structures are required.
· Knowledge of UB-04s, CMS 1500 forms, and itemized statements
· Demonstrated ability to establish and manage performance and outcome metrics.
· Strong overall Microsoft Office skills with an emphasis on Excel skills
· Excellent collaboration and communication skills with the ability to partner effectively across the organization and with external partners.
· Understanding of individualized complex care plans
· Understands and recognizes medical and insurance terminology
· Strong strategic thinker and tactical performer
· Strong project management skills with the demonstrated ability to handle multiple projects.
· Ability to establish and maintain positive and effective work relationships with internal staff, external vendors, and state and federal agencies
· Proven skills and judgment necessary for independent decision-making.
· Excellent organizational, time-management and problem-solving skills