Payment Integrity Analyst

About the role

The Payment Integrity Analyst executes claims investigation and recovery strategies, analyzes claims data to identify cost containment opportunities, and conducts in-depth claims audits. The role involves reviewing and analyzing new audit concepts, making recommendations for recoveries, and partnering with vendors on recovery audits. The analyst coordinates with internal business partners such as Clinical, Contracting, Configuration, Finance, Claims, and Provider Relations to ensure alignment of efforts and supports all recovery initiatives for claims processing.

Responsibilities

• Implement new Payment Integrity initiatives as directed by the Payment Integrity Manager and/or Director.
• Partner with others on the Payment Integrity or Claims teams to ensure collaboration, communication, and knowledge sharing.
• Review published Centers for Medicare and Medicaid Services (CMS)/Recovery Audit Contractor (RAC) topics for viability of CareOregon’s paid claims.
• Review vendor overpayment suggestions for accuracy, adherence to scope, claim recovery activities, new concepts submission, and claim sample approval.
• Interact with claims payment vendor and internal departments to discuss system corrections and recommendations regarding claims overpayments.
• Identify and document root causes of overpayments along with remediation recommendations.
• Research and audit simple to complex claims payments using tools provided by the Oregon Health Authority (OHA), Medicare billing guidelines, CareOregon’s claims processing policies, and other resources.
• Enter and update recovery information in claims systems, call tracks, and other payment integrity tools.
• Prepare and create accurate and timely provider overpayment notification letters with reconciliation backup documentation.
• Consistently meet work/performance standards, including payment integrity goals, productivity, quality metrics, and monthly savings goals.
• Communicate effectively and professionally with internal and external customers regarding recovery, claims payment, provider remittances, and general recovery processes.
• Handle calls from providers related to overpayment requests/activities.
• Research and resolve payment disputes and provide timely follow-up.
• Maintain a working knowledge of regulations relevant to payment recovery and claims processing.
• Promptly escalate complex issues to the Payment Integrity Manager.
• Perform necessary claims adjustments identified in audits when needed.
• Support User Acceptance Testing (UAT) for large-scale testing projects when needed.

Requirements

• Minimum 3 years’ experience in roles using Medicare and/or Medicaid claims management systems.
• Minimum 1 year’s experience performing advanced claims adjustments.

Preferred Qualifications

• 2 years of QNXT experience.
• Certification in clinical coding (e.g., Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Medical Coder (CMC), Certified Coding Associate (CCA)).
• Experience performing statistical claims analysis in a managed care or healthcare setting.
• Experience with payment integrity programs and/or vendors.
• Experience with SQL Server Reporting or business intelligence tools (e.g., Tableau) and data frameworks.

Skills

• Working knowledge of claims coding requirements and payment methodologies (e.g., Prospective Payment System (PPS), Medicare Fee Schedules).
• Knowledge of medical terminology.
• Skill in using claims management systems, editing software, and medical coding.
• Solid understanding of complex claims processing and payment integrity/payment policy initiatives, including manual pricing, coordination of benefits (COB), and adjustments.
• Ability to learn state and federal claims and payment integrity regulations.
• Strong statistical, analytical, and problem-solving skills.
• Strong organizational and detail-orientation skills.
• Adept at prioritizing work and working well under pressure in a complex, rapidly changing environment.
• Good spoken and written communication skills.
• Ability to present complex information to groups as needed.
• Excellent interpersonal skills and ability to work effectively with diverse individuals and groups.
• Ability to work independently and present a positive, professional image.
• Advanced skill in Excel.
• Ability to learn, focus, understand, and evaluate information to determine appropriate actions.
• Ability to accept direction and feedback, as well as tolerate and manage stress.
• Ability to see, read, and perform repetitive finger and wrist movements for at least 6 hours/day.
• Ability to hear and speak clearly for at least 3-6 hours/day.

Working Conditions

• Indoor/office environment.
• Not member/patient-facing in person; may involve telephonic interaction.
• Hazards may include physical and ergonomic risks.
• Use of general office equipment.
• Occasional travel outside the workplace may be required; personal vehicle, local transit, or other transportation may be used.
• Work location: Work from home.

Pay

Estimated hiring range: $32.06 - $39.19 per hour.

Bonus: Target 5% annual SIP (Sales Incentive Plan) bonus.

Benefits

CareOregon offers a comprehensive benefits package for eligible employees, including:

• Medical, dental, vision, life, AD&D, and disability insurance.
• Health savings account (HSA) and flexible spending account(s) (FSA).
• Lifestyle spending account.
• Employee assistance program and wellness program.
• Discounts and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings).
• Retirement plan with employer contributions.
• Paid time off (PTO), paid state sick time, and paid holidays (eligibility varies).
• Volunteer time, jury duty, and bereavement leave (eligibility varies).

Non-benefits eligible employees receive 401(k) contributions, paid state sick time, wellness and employee assistance program benefits, and other perks.