Lead Payment Integrity Analyst

Responsibilities

• Oversees the financial and key performance indicators related to pre-pay integrity services, post-pay integrity services, premium revenue services, and remediation initiatives to ensure financial and key performance targets are met.
• Collaborates with enterprise stakeholders across the organization to proactively identify issues and implement resolution strategies.
• PARTNER WITH PROVIDER NETWORK MANAGEMENT TO COMMUNICATE RECOVERY PROJECTS TO BE INFORMED AND RESPOND TO QUESTIONS FROM PROVIDERS.
• DOCUMENTS CONTROLS, BUSINESS DECISIONS, AND PAYMENT INTEGRITY OVERSIGHT TO DISSEMINATE TO THE EXECUTIVE TEAM MEMBERS AND INTERNAL AUDIT COMMITTEE.
• ENSURES ACCURATE INTERPRETATION OF MEDICAL CLAIMS TRENDS, PAYMENT INTEGRITY ISSUES, AND PROCESS GAPS.
• SHAPES ACTION PLANS BY APPLYING UNDERSTANDING OF HEALTHCARE REGULATIONS, MANAGED CARE CLAIMS WORKFLOWS, AND PROVIDER REIMBURSEMENT MODEL.
• TRANSLATES STRATEGIC NEEDS INTO CLEAR REQUIREMENTS, WORKFLOWS, AND SOLUTIONS THAT DRIVE MEASURABLE IMPROVEMENT.
• PARTNERS WITH FINANCE, QUALITY ASSURANCE, AND COMPLIANCE TO DEVELOP BUSINESS CASES AND SUPPORTS REPORTING THAT TIES OPERATIONAL OUTCOMES TO FINANCIAL TARGETS.

Qualifications

• Bachelor's degree with 6+ years of payment integrity, claims processing, quality or process improvement experience, including performance measurement systems OR associate degree with 9+ years of experience of payment integrity, claims processing, quality or process improvement experience, including performance measurement systems OR high school equivalency with 12+ years of payment integrity, claims processing, quality or process improvement experience, including performance measurement systems.
• MUST HAVE EXPERIENCE WITH: Payment integrity programs, Health insurance claims processing, Leading cross-functional workgroups, Project management, Lean Six Sigma or problem-solving methodologies.
• STRONG BUSINESS JUDGMENT, STRONG UNDERSTANDING OF CLAIMS REIMBURSEMENT, PROFICIENT IN DATA ANALYTIC TOOLS, COMPATIBLE WITH INTERFACING WITH EXECUTIVES ACROSS THE ORGANIZATION, AND HOLDING CROSS-FUNCTIONAL PEERS ACCOUNTABLE.
• STRONG INTERPERSONAL SKILLS AND ADAPTIVE COMMUNICATION STYLE, COMPLEX PROBLEM-SOLVING SKILLS, DRIVE FOR RESULTS, AND INNOVATIVE.
• PROVEN TRACK RECORD OF DELIVERING RESULTS IN PROJECTS.

Benefits

• Starting salary is based upon skills and experience: $77,200 - $96,500 plus robust benefits package.