Payment Integrity Supervisor

About the role

The Payment Integrity Supervisor is responsible for the daily activities of the payment integrity team related to quality assurance and provider appeals. The Supervisor manages and prioritizes staff daily work assignments necessary to ensure the timely and accurate processing of internal and external requests, interdepartmental quality audits and appeals. Additionally, the supervisor works to reduce response timeframes and mitigate future inquiries or escalations by being proactive, taking ownership of challenges, and formulating solutions to improve overall department activities while maintaining a focus on improving how we deliver service to our customers.

Responsibilities

• Supervises all daily activities of the payment integrity team related to quality assurance and provider appeals
• Absorbs and assists team with problem-solving, payer policy, and clinical questions regarding audits performed by CERIS
• Reviews and applies clinical knowledge along with payer policy to charges submitted on UB's, itemized bills, and medical records to determine accuracy of charges billed
• Ensures new employees are oriented to the organization, its policies, facilities, etc.
• Provides ongoing guidance to employees, often in the forms of ongoing career coaching, counseling, and performance appraisal
• Responsible for ensuring appeals and grievances are resolved in a timely manner
• Demonstrate ability to manage multiple projects, set priorities, and manage to committed schedule
• Keeps manager informed of any issues that arise with appeals, quality assurance, and/or team that cannot be resolved
• Act as a point of contact for internal departments to answer and resolve any questions related to appeals and quality assurance
• Prepares and distributes reporting materials and team training presentations as directed by the manager
• Maintains HIPAA privacy and security protocols
• Performs audits and/or appeal reviews as necessary

Requirements

• Strong understanding of claims processing, ICD-10 Coding, DRG Validation (if applicable)
• Strong understanding of healthcare claims reimbursement
• Proficient in Microsoft Office including Excel and Word
• Strong interpersonal skills and adaptive communication style, complex problem-solving skills, drive for results, innovative
• Excellent written and verbal communication skills
• Ability to think and work independently, while working in an overall team environment
• Strong attention to detail and ability to deliver results in a fast-paced and dynamic environment

Qualifications

• Associate Degree in Nursing or higher required as applicable. BSN preferred
• Must maintain current licensure as a Registered Nurse in the state of employment as applicable
• Maintain current coding certification as applicable
• Completes required CEUs to maintain Registered Nurse license and/or coding certification as applicable
• Demonstrated knowledge of CMS guidelines and ICD-10 coding guidelines as applicable
• 5+ years 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 preferred for non-DRG audits
• As applicable for DRG roles, CCS or CIC required with DRG auditing experience in ICD-10-CM, ICD-10-PCS
• Proficiency in both MS and APR DRG reimbursement methods
• Demonstrated knowledge and understanding of clinical criteria documentation requirements used to successfully substantiate code assignments
• 2+ years medical claims auditing of inpatient, outpatient and ASC claims preferred
• 2+ years supervisory or management experience

Skills

• Strong understanding of claims processing, ICD-10 Coding, DRG Validation (if applicable)
• Strong understanding of healthcare claims reimbursement
• Proficient in Microsoft Office including Excel and Word
• Strong interpersonal skills and adaptive communication style, complex problem-solving skills, drive for results, innovative
• Excellent written and verbal communication skills
• Ability to think and work independently, while working in an overall team environment
• Strong attention to detail and ability to deliver results in a fast-paced and dynamic environment

Benefits

• Comprehensive benefits package available for full-time regular employees
• 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