Payment Accuracy Specialist 1

About the role

Cotiviti Healthcare is a leading provider of payment accuracy services to the healthcare and retail industries. We are seeking innovative thinkers and creative problem solvers who are interested in making a contribution to improving healthcare and want to be part of a team that is expanding rapidly and providing opportunities for career growth.

Responsibilities

• Conducts or assists in the identification, validation, and documentation of moderate to more complex audit projects.
• Documents relevant facts, information, and conclusions drawn to support the work performed and validate the claim.
• Utilizes this information to knowledge share within the audit team.
• Builds and maintains a solid understanding of Centers for Medicare and Medicaid Services (CMS) and National Association of Insurance Commissioners (NAIC) guidelines to establish the correct order of liability.
• Proficient with Cotiviti audit tools Recovery Management System (RMS), specific client systems to complete auditing, review simple - medium proprietary reports, and has an advanced understanding of Microsoft Excel and client applications.
• Audits standard reports and paid claims to identify over and under-payments of claims.
• Enters overpayments into Cotiviti system accurately and in accordance with standard procedures.
• Identifies and discusses audit findings with the audit team as a part of knowledge sharing and concept expansion.
• May update current reports, develop, and run custom queries and validate the accuracy of current reports used.
• Makes determinations based on prior knowledge and experience of client contract terms with the likelihood of recovery acceptance.
• Maintains regular and predictable attendance and meets or exceeds standards for productivity, claims written, vendor/project volume completion, ID, and/or fees per hour.
• Maintains the expected level of quality and quantity for assigned work, including hit rate, claims written, vendor/project volume completion, ID, and/or fees per hour.
• Maintains the expected level of quality and quantity for assigned work, including hit rate, claims written, vendor/project volume completion, ID, and/or fees per hour.
• Responds effectively to inquiries received on claims written.
• Provides verification of claims validation and confirmation, in a concise written manner, utilizing facts and details for justification purposes.
• Identifies and suggests new claim types and concept expansion by researching and identifying potential claims outside the audit concept.
• Suggests, develops, and analyzes high quality, high value concepts and/or process improvements, tool enhancements, etc.
• Collaborates with Engineering in the development of new reports.
• Evaluates information and draws logical conclusions.
• Uses learned, tried, and proven validation methods to test and produce the desired/intended result of the new concept.
• Ensures confidentiality and security of all data, adhering to all HIPAA (Health Insurance Portability and Accountability) laws and requirements.
• Works towards developing and implementing new ideas, approaches, and/or technological improvements that will support and enhance audit production.
• Ensures the expected level of quality and quantity for assigned work, including hit rate, claims written, vendor/project volume completion, ID, and/or fees per hour.

Qualifications

• High School Diploma - Required.
• Bachelor’s degree (Preferred) and/or a minimum of at least (2 - 4) year/s related experience in healthcare.
• At least 2 - 3 years of Cotiviti experience is recommended for individuals seeking their next opportunity internally.
• Healthcare industry experience, including knowledge of Medicaid Claims is strongly preferred.
• Computer proficiency including Microsoft Office (Word, Excel, Outlook, Access).
• Excellent verbal and written communication skills.
• Strong interest in working with large data sets and various databases.
• Ability to work well in an individual and team environment demonstrating self–motivation to deliver success.
• Cognitive/Mental Requirements: Ability to analyze large volumes of data, identify trends, discrepancies, and anomalies. Must have exceptional attention to detail to ensure accuracy in financial records and audit findings. Demonstrates strong critical thinking skills, with the ability to assess complex situations, identify key issues, and propose practical solutions. Able to approach challenges methodically and with a strategic mindset. Make informed decisions based on available data, regulations, and auditing standards. Must be able to weigh options and make recommendations that align with both compliance requirements and organizational goals. Strong understanding of auditing standards, regulations, and industry best practices. Must be able to apply these standards consistently to ensure accurate and compliant audit processes. Ability to recognize when something is wrong or needs further investigation. Must have the initiative to probe deeper into financial records or processes to uncover issues, inconsistencies, or irregularities. Ability to work effectively as part of an audit team, sharing insights, collaborating on tasks, and contributing to a positive and productive team dynamic. Demonstrates strong time management skills with the ability to juggle multiple tasks simultaneously and efficiently.
• Physical Requirements And Working Conditions: Remaining in a stationary position, often standing or sitting for prolonged periods. Repeating motions that may include the wrists, hands, and/or fingers. Must be able to provide a dedicated, secure work area. Must be able to provide high-speed internet access/connectivity and office setup and maintenance. No adverse environmental conditions expected.