Payment Integrity Analyst

About the role

The Payment Integrity Analyst is responsible for executing claims investigation and recovery strategies, analyzing claims data to identify cost containment opportunities, and conducting in-depth simple to complex claims audits. The role reviews and analyzes new audit concepts, makes recommendations for recoveries, and partners with vendors on additional recovery audits and investigations. The position coordinates with internal business partners in Clinical, Contracting, Configuration, Finance, Claims, and Provider Relations to ensure efforts are in sync and supports all recovery efforts 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 to maximize team efforts and efficiency.
• 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 procedures, and other resources to identify claims overpayments.
• 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 and include them with reconciliation backup documentation.
• Consistently meet work/performance standards that include payment integrity goals, productivity, quality metrics, and monthly savings goals.
• Communicate effectively and in a professional manner with internal and external customers regarding all aspects of recovery, claims payment, provider remittances, and general recovery processes.
• Make and take 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 encountered to the Payment Integrity Manager.
• Perform necessary claims adjustments identified in audits when/if needed.
• Support User Acceptance Testing (UAT) for large-scale testing projects when/if needed.

Requirements

• Minimum 3 years experience in roles using Medicare and/or Medicaid claims management systems.
• Preferred: Minimum 1 year experience performing advanced claims adjustments.
• 2 years of QNXT experience.
• Experience performing statistical claims analysis in a managed care or health care setting.
• Clinical coding certification(s), such as Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Medical Coder (CMC), Certified Coding Associate (CCA), etc.
• Experience with payment integrity programs and/or vendors.
• Experience with SQL Server Reporting, or using 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, etc.).
• Knowledge of medical terminology.
• Knowledge and 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), adjustments, etc.
• Ability to learn state and federal claims and payment integrity regulations.
• Ability to use computer programs commonly used for health plan operations.
• Statistical, analytical, and problem-solving skills.
• Strong organization skills and strong detail-orientation skills.
• Adept at prioritizing work and working well under pressure in a complex and 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 independently or effectively with diverse individuals and groups.
• Ability to accept direction and feedback, as well as tolerate and manage stress.
• Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day.
• Ability to hear and speak clearly for at least 3–6 hours/day.
• Advanced skill in Excel helpful.

Benefits

• Medical, dental, vision, life, AD&D, and disability insurance.
• Health Savings Account and Flexible Spending Account(s).
• 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 and Paid State Sick Time based on hours worked/scheduled hours and primary work state.
• Paid holidays, volunteer time, jury duty, and bereavement leave, depending on eligibility.
• 401(k) contributions for non-benefits eligible employees.

Pay

Estimated Hiring Range: $32.06 – $39.19 per hour. Bonus Target: SIP Target, 5% annual.