Lead, Payment Integrity

Western Growers Family of Companies

5d•$61,719 - $80,234•Hybrid

About The Position

This position reports to the Manager of Payment Integrity and performs in-depth quality claim audits to ensure company standards are being met along with providing support in recovery and receivables. In addition, this position will provide reporting and training support to the Claims Department.

Requirements

High school Diploma or equivalent and a minimum four (4) to six (6) years of recent experience as a medical, dental, vision and specialty claims auditor.
Strong knowledge of basic revenue and receivables business math and operations.
Knowledge of Current Procedural Terminology (CPT) and International Statistical classification of Diseases and Related Health Problems (ICD 11 & ICD-10 & ICD-9) and medical terminology.
Strong understanding of CMS, HIPAA, MEWA, ERISA, and Perspective Payment Systems reimbursement regulations and compliance.
Exceptional understanding and interpretation of summary plan descriptions of employee medical/dental/vision and specialty benefits.
Exceptional ability to interpret provider contracts, plan documents, respond to questions and train in depth claim form issues.
Proven ability as a self-starter to manage timelines and commitments.
Proficient in end-user software, e.g. word-processing and spreadsheets.
Exceptional written and verbal communication skills.
Ability to apply critical thinking and demonstrate sound judgement in a variety of situations.
Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client data.
Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.
Home router with wired Ethernet (wireless connections and hotspots are not permitted).
A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)
A functioning smoke detector, fire extinguisher, and first aid kit on site.

Nice To Haves

Six years’ experience processing group health claims, preferred.
Accounting or Receivables background preferred.
Basic familiarity with electronic data interchange (EDI) transactions (e.g., 835 and 837 files), preferred.

Responsibilities

Identify and escalate issues related to instructional and claims procedures, work instructions, or workflows that are inaccurate, unclear, contain gaps, or have not been created.
Provide support in enhancing Payment Integrity guidelines and workflows.
Facilitate the development of process documentation.
Document business rules for incorporation into training programs, policies and procedures.
Provide research and root cause analysis for claims quality remediation.
Perform special project audits and reviews, including auditing selected claims before the nightly payment run, as requested by claims leadership.
Monitor standard EDI error and rejection reports and make corrections as assigned.
Monitor 835 & 837 error reports, correcting discrepancies and identifying opportunities to reduce error rates.
Lead operational oversight of network payment posting and reconciliation, driving consistency, accountability, and performance.
Perform moderately and highly complex audits on paper and electronic claims for payment integrity in alignment with regulatory and timelines standards, business policy, and contract terms.
Research claim processing problems and errors to determine their origin and appropriate resolution. Communicate with management regarding trends to improve claims processing accuracy.
Research, review and analyze all overpayments, refunds and voids relating to medical, dental, and vision claims.
Provide support to collect receivables for the Western Growers Assurance Trust (WGAT) and clients of the Third-Party Administrator (TPA) that may be a result of overpayments or claims adjustments by researching, writing letters, and actively making phone calls.
Research and respond to inquiries from other departments related to claim financial transactions within the required turn-around time.
Prepare reports, summarize observations and prepare recommendations for management.
Perform special project audits and reviews as requested by other departments/regions.
Perform review and audit of Payment Integrity Staff work via “Audit the Payment Integrity Team” program.
Provide Subject Matter Expert (SME) support for new hire training, individual, and uptraining classes.
Assist existing staff with claims questions and complex claims topics.
Provide support to the training team with new hires, Nesting Team, and up-training curriculum recommendations.
Participate in claims staff development and performance improvement plans by providing additional auditing and coaching.
Support the development of a culture of accountability by modeling the behavior that defines it.
Participate in developing and leading a team of 3A+ self-accountable professionals.
Participate in team meetings and one-one conversations along with the Manager of Payment Integrity.
Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning and executing work in a helpful and collaborative manner, being willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating positive impact and being diligent in delivering results.
Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.
Maintain a HIPAA complaint workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.
Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).
All other duties as assigned.