Payment Integrity Analyst

About the role

Applies analytical and technical skills and assist in development of solutions to prevent overpayments identified by vendors and through other means. Applies root cause analysis findings to assist with developing overpayment prevention solutions and assist implementation efforts within Priority Health. Works with vendors and other key business areas to address effectiveness of overpayment prevention solutions and identify potential solution enhancements as necessary. Also may be responsible for stop loss analysis.

As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.

Primary Location: Priority Health, 1239 E Beltline Ave NE, Grand Rapids. Department: Payment Integrity Planning and Implementation - PH Managed Benefits. Employment Type: Full time.

Responsibilities

• Coordinate with vendors to review findings and identify methods to increase claims payment accuracy and integrity.
• Ability to manage and resolve conflicting points of view from providers and internal departments (includes appeals to health plan for Payment Integrity initiatives).
• Analyze results of ongoing leakage and prevention monitoring to identify inefficiencies and improve solution effectiveness.
• Coordinate and support activities related to vendor contracts.
• Manage proper controls for vendor invoicing, validation, reconciliations and adjustments.
• Prepare check requests for vendor payments.
• Coordinate with other departments as needed to accomplish cross–departmental projects and/or goals.
• Analyze and review initial, subsequent and or final filings to ensure submissions received are covered and eligibility requirements are satisfied per the groups stop loss policy (SPD, stop loss policy, fee disclosure).
• Examine claims for stop loss eligibility including verifying stop loss coverage, eligibility (knowledge of plan eligibility requirements including FMLA, MLOA, COBRA).

Qualifications

• Associate's Degree or equivalent preferably in a health or business related degree
• 2 years of relevant experience
• Health plan operations experience to include end to end claims operations and processes.
• Experience with root cause analysis.
• CRT-Professional Coder - AAPC American Academy of Professional Coders Upon Hire preferred
• Or CRT-Coding Specialist (CCS) - AHIMA American Health Information Management Association Upon Hire preferred
• Or CRT-Coding Specialist, Certified-Physician Based (CCS-P) - AHIMA American Health Information Management Association Upon Hire preferred
• Or CRT-Registered Health Information Administrator (RHIA) - AHIMA American Health Information Management Association Upon Hire preferred