Payment Integrity Analyst III - QA Analyst

About the role

The Payment Integrity Analyst (Team Lead) assists with leading the Policy and Payment Integrity (PPI) team while maintaining the regular duties and responsibilities of this role which is accurately reviewing pre and post pay claim audits based on client, policy, industry standards and/or CMS guidelines.

Responsibilities

• Assists with staff communication, providing updates, resolving issues, setting goals and maintaining standards as well as dialogue with team members in efforts to answer their questions and resolve barriers
• Oversees team member work for quality and compliance and communicates deadlines and productivity goals to team members while providing ongoing training and education to staff to ensure policies and procedures are followed
• Verifies and corrects as necessary, the audit work completed by PPI QC analysts and clinical appeal review teams as needed
• 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
• Ability to use clinical judgement and analytical skills to appropriately review documentation submitted for claim audits
• Utilize 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
• Utilize applicable tools and resources to complete internal audits and/or appeals
• Timely completion of internal audits and/or appeals
• Attends Clinical Team Meetings, All Company Meetings, Education Opportunities, Trainings, and other potential meetings

Requirements

Must maintain a current LPN, LVN and/or RN licensure (this applies only to RN hires, not coders)

Preferred experience with health insurance denials and/or appeals, payer audits, or vendor audits

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

Bachelor’s degree in healthcare or related field preferred

3+ years healthcare revenue cycle or payment integrity experience

3+ years of relevant experience or equivalent combination of education and work experience

Qualifications

Ability to demonstrate understanding of CMS and commercial payer policy in written and verbal format

Strong understanding of claims processing, ICD-10 Coding, DRG Validation, Coordination of Benefits

Strong understanding of healthcare revenue cycle and claims reimbursement

Proficient in Microsoft Office including Pivot Tables and Database Management

Demonstrate ability to manage multiple projects, set priorities and adhere to committed schedule

Strong interpersonal skills and adaptive communication style, complex problem-solving skills, drive for results, innovative

Excellent written and verbal communication skills

Proven track record of delivering concrete results in strategic projects/programs

Strong analytical and modeling ability and distilling data into actionable results

Superb attention to detail and ability to deliver results in a fast paced and dynamic environment

Skills

Ability to use clinical judgement and analytical skills to appropriately review documentation submitted for claim audits

Utilize 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

Utilize applicable tools and resources to complete internal audits and/or appeals

Benefits

A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off.