Payment Accuracy Specialist 2

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

• Develops new and existing audit concepts, gaining client acceptance, and training all Specialist levels to execute audit projects.
• Evaluates the effectiveness of audit concepts.
• Works under moderate supervision and monitors for efficiency in production and quality review of assigned work.
• Built and maintains a basic understanding of Centers for Medicare and Medicaid Services (CMS) and National Association of Insurance Commissioners (NAIC) guidelines to establish the correct order of liability.
• Advanced with Cotiviti audit tools Recovery Management System (RMS), specific client systems to complete auditing, review simple - medium proprietary reports, and have an expert understanding of Microsoft Excel and client applications.
• Utilizes healthcare experience to perform audit procedures that include identifying and defining issues, developing criteria, reviewing, and analyzing evidence with the intent to audit medium and complex reports.
• Work is advanced in scope and complexity. Knowledge is applied to resolve routine issues, as necessary.
• Knowledgeable in Data Mining, Claim Adjudication, Contract Compliance, Provider Billing & Duplicate Payment Reviews, Policy & Reimbursement Analysis, and Quality Assurance.
• Advanced analysis of paid claims and identification of audit findings including documentation for training and knowledge sharing.
• Works with Engineering to increase the efficiency of tools and reporting.
• Makes determinations based on prior knowledge and experience of client contract terms with the likelihood of recovery acceptance.
• Meets or Exceeds Standards for Productivity in addition to regular and predictable attendance, maintains production goals and standards set by the audit for the auditing concept.
• Meets or Exceeds Standards for Quality by Achieving the expected level of quality set by the audit for the auditing concept, for valid claim identification and documentation.
• Highly proficient, subject matter expert in responding to inquiries and disputes received on all claims written.
• Provides verification of claims validation and confirmation, in a concise written manner, utilizing facts and details for justification purposes.
• Demonstrates aptitude in reviewing transaction types, client contracts/vendor agreements, and client data with limited supervision of how to identify potential over or underpayments.
• Makes recommendations on medical policy applications, state and federal statutes, and other reimbursement methodologies as it applies to the audit concept.
• Considered a skilled resource in onboarding new hires and/or training existing staff on new concepts and processes.
• Identifies New Claim Types & Concept Expansion by using proven methodologies to research and substantiate claims outside the audit concept.
• Enlists others internally or externally to help validate, suggest, develop, and analyze high-quality, high-value concepts and/or process improvements, tool enhancements, etc.
• Strong driver and voice in the development of audit concepts. Recommends New Concepts & Processes based on experience and in-depth knowledge of client contract terms and complex claim types.
• Uses advanced validation methods to test and produce a desired/intended result of the new concept.
• Regularly collaborates with Engineering in the development of new reports and tool functionality.
• Ensures confidentiality and security of all data, adhering to all HIPAA (Health Insurance Portability and Accountability) laws and requirements.
• Ensures confidentiality and security of all data, adhering to all HIPAA (Health Insurance Portability and Accountability) laws and requirements.
• 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.

Qualifications

• High School Diploma - Required.
• Bachelor’s degree (Preferred) and/or a minimum of at least (4 - 6) year/s related experience in healthcare.
• At least 3 - 4 year/s of Cotiviti experience is recommended for individuals seeking their next opportunity internally.
• Healthcare industry experience, including knowledge of claim adjustments, provider contracts, reimbursement policies and payment integrity.
• (strongly preferred).
• Computer proficiency including Microsoft Office (Word, Excel, Outlook, Access).
• Previous SQL experience strongly preferred.
• 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.
• Understands and embodies Cotiviti Core Values, Strategic Pillars, and Operations Disciplines to achieve successful performance in completing assigned responsibilities and interactions with the Organization both internally and externally.