Payment Integrity Analyst II

Essential Functions & Responsibilities

Reviews, analyzes, and completes internal audits and/or appeals in accordance with client policy, CMS guidelines and industry standards in clear and professional written communication.

Uses clinical judgement to appropriately interpret and apply client policies along with CMS guidelines as it relates to reviews done by CERIS such as itemized bill, DRG and/or specialty audits.

Utilizes applicable tools and resources to complete internal audits and/or appeals.

Timely completion of internal audits and/or appeals.

Attends clinical team meetings, company meetings, educational opportunities/trainings, and other meetings.

Knowledge & Skills

• Ability to use clinical judgment and analytical skills for claim audit review.
• Knowledge of CMS/commercial payer policies, claims processing and reimbursements, IDC-10 Coding, and DRG Validation.
• Familiarity with healthcare revenue cycle and coordination of benefits.
• Proficiency in Microsoft Office, especially using pivot tables in Excel as well as and database tools.
• Excellent written and verbal communication skills.
• Strong interpersonal skills across all levels; comfortable interfacing with clients and the C-Suite.
• Able to work on several concurrent tasks and prioritize workload to meet designated deadlines.
• Advanced problem-solving and data analysis capabilities.
• Prominent track record of delivering actionable results.
• Strong attention to detail.

Education & Experience

• Maintains a current LPN, LVN and/or RN licensure.
• Previous experience in one or more of the following areas required: Medical bill auditing, experience in the acute clinical areas of facilities in O.R., I.C.U., C.C.U., E.R., Telemetry, Medical/Surgical, OB or L&D, Geriatrics and Orthopedics, knowledge of worker's compensation claims process, prospective, concurrent and retrospective utilization review, 1+ years healthcare revenue cycle, 1+ years of relevant experience or equivalent combination of education and work experience, 1+ years hospital bill audit, Bachelor’s degree in healthcare or related field preferred.
• Preferred experience with health insurance denials and/or appeals, payer audits, or vendor audits.