Payer Compliance Specialist I - Remote

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Follows the payer compliance management standard operating procedures.
• Analyzes, evaluates, and validates payer under and over-allowable variances in work queues.
• Manages corrective actions to resolve the variances via appeal, cross-workflow, or escalation to management.
• Gathers appeal documentation and files the appeal to various payers as appropriate.
• Follows up on appeal results 45-60 days post appeal submission.
• PARTNERS WITH LEADERSHIP TO RESEARCH AND REPORT PAINTER SYSTEMIC ISSUES CREATING VARIANCE TRENDS.
• Uses the out-of-model guidance matrix to assist with accurately and consistently reporting over-allowed variances to leadership and finance.
• Learns and familiarizes payer policies and contractual terms associated with the payer to which the analyst is assigned.
• Researches refund requests sent via correspondence cross-workflow, appropriately responds, and/or takes action.
• Inquires with leadership and the contract management team on potential contract term discrepancies.
• Communicates regularly with the management team regarding payer variance issues.

QUALIFICATIONS

• High school graduate or equivalent required.
• Minimum of 2 years experience in healthcare revenue cycle.
• Functional knowledge of Excel and Word required.
• Basic knowledge of managed care programs and healthcare billing requirements necessary.
• Analytical abilities to identify and resolve underpayments relating to specific payers, coding issues, etc. are required.
• Good mathematical, verbal, and written communication skills.
• Experience gathering and reporting information.
• Must display a teamwork attitude and possess good interpersonal skills.
• Ability to work independently with limited supervision.
• Familiarity with basic medical terminology and concepts preferred.
• Knowledge of CPT, ICD-9, and ASA coding preferred.