Payment Integrity Analyst (Remote)

CareFirst of Maryland•Baltimore, MD

4d•Remote

About The Position

PURPOSE: The Payment Integrity Analyst is responsible for conducting research and analysis and reviewing billing requirements, provider manuals, medical policies, and other sources as needed to identify new overpayment concepts, as well as validate all prospective and retrospective overpayment results; communicating findings to the Payment Integrity Workgroup and Management. The incumbent will be responsible for assessing and implementing new technology and recommend improvement to existing processes. In addition, they will be responsible for providing thorough analysis on their findings.

Requirements

Bachelor's Degree in Health Information Management, Data Analytics or equivalent work experience required.
Certified Professional Coder.
3 years year's relevant experience (healthcare claims reimbursement methodologies, claims, and data analysis).
Strong analytical, conceptual and problem-solving skills to evaluate complex business requirements.
Ability to tell the story of the analysis to gain consensus across business units on overpayment items.
Effective written and oral communication skills.
Ability to review and understand CareFirst medical policies, claim payment policies and provider manuals.
Microsoft Excel, Word, and Access.
Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Must be eligible to work in the U.S. without Sponsorship

Nice To Haves

Master's Degree in Health Administration, Information Systems, or related field.

Responsibilities

Identifies, develops, and implements new concepts that will target claim overpayment scenarios.
Performs analysis on claims, provider data, enrollment data, medical policies, claim payment policies for payment integrity concepts for recovery opportunities.
Performs analysis of business unit data and policies, applying a thorough understanding of each line of business specific procedures, to make recommendations to Payment Integrity workgroup and management to reduce and/or eliminate erroneous payment exposure with minimal direction.
Identifies and produces root cause analysis when overpayment and cost avoidance concepts are identified to management. Responsible for not only the recovery of the concept but working with each operation to make any necessary technical update to avoid the overpayments moving forward.
Tracks and reports progress of current prospective and retrospective cost avoidance/ overpayment recovery concepts.
Responsible for carrying out new concepts within the established deadlines with a high level of accuracy.
Responsible for resolving any challenges made to the proposed cost avoidance/overpayment concepts throughout the organization working with Provider Network, Provider Contracting, Medical management and policy and Legal.
Stakeholder in a cross functional working team to develop and implement new overpayment/cost avoidance concepts.
Reviews claims edit concept results for quality assurance and proof of concept validation.
Reviews all available sources including federal and state statutes, regulations, provider manuals, Provider contracts, and bulletins for changes to and/or new payment rules.
Identifies and documents changes to and/or new payment rules or language in the source document which may be utilized to update existing system edits or new system edits.