Payment Integrity Analyst

CareOregon•Washington, DC

1d•$32 - $39•Remote

About The Position

The Payment Integrity Analyst is responsible for executing claims investigation and recovery strategies. This includes analyzing claims data to identify cost containment opportunities across many different claims areas to ensure proper claims payments, as well as conducting in-depth simple to complex claims audits. The Payment Integrity Analyst also works to review and analyze new audit concepts and make recommendations for recoveries and partners with our vendors on additional recovery audits and investigations. The position coordinates with internal business partners in other areas such as Clinical, Contracting, Configuration, Finance, Claims and Provider Relations to ensure efforts are in sync. The role is integral in ensuring claims payment integrity as it supports all recovery efforts for claims processing.

Requirements

Minimum 3 years’ experience in roles using Medicare and/or Medicaid claims management systems
Minimum 1 year’ experience performing advanced claims adjustments
Working knowledge of claims coding requirements and payment methodologies (e.g. Prospective Payment System (PPS), Medicare Fee Schedules, etc.)
Knowledge of medical terminology
Knowledge and skill in using claims management systems, editing software and medical coding
Solid understanding of complex claims processing and payment integrity/payment policy initiatives including manual pricing, coordination of benefits (COB), adjustments etc.
Ability to learn state and federal claims and payment integrity regulations
Ability to use computer programs commonly used for health plan operations
Statistical, analytical and problem-solving skills
Strong organization skills
Strong detail-orientation skills
Adept at prioritizing work
Ability to work well under pressure in a complex and rapidly changing environment
Good spoken and written communication skills
Ability to present complex information to groups as needed
Excellent interpersonal skills
Ability to work independently
Ability to work effectively and professionally with diverse individuals and groups related to the provision of services
Ability to present a positive and professional image as a leader and representative of CareOregon
Ability to learn, focus, understand, and evaluate information and determine appropriate actions
Ability to accept direction and feedback, as well as tolerate and manage stress
Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
Ability to hear and speak clearly for at least 3-6 hours/day

Nice To Haves

2 years of QNXT experience.
Certification Experience performing statistical claims analysis in a managed care or health care setting
Clinical coding certification(s), such as Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Medical Coder (CMC), Certified Coding Associate (CCA), etc.
Experience with payment integrity programs and/or vendors
Experience with SQL Server Reporting, or using business intelligence tools (e.g. Tableau) and data frameworks
Advanced skill in Excel helpful

Responsibilities

Implement new Payment Integrity initiatives as directed by the Payment Integrity Manager and/or Director.
Partner with others on the Payment Integrity or Claims teams to ensure collaboration, communication and knowledge sharing to maximize team efforts and efficiency.
Review published Centers for Medicare and Medicaid Services (CMS)/Recovery Audit Contractor (RAC) topics for viability of Care Oregon’s paid claims.
Review vendor overpayment suggestions for accuracy, adherence to scope, claim recovery activities, new concepts submission and claim sample approval.
Interact with claims payment vendor and internal departments to discuss system corrections and recommendations regarding claims overpayments.
Identify and document root causes of overpayments along with remediation recommendations.
Research and audit simple to complex claims payments including researching tools provided by the Oregon Health Authority (OHA), Medicare billing guidelines, CareOregon’s claims processing policies and procedures and other resources to identify claims overpayments.
Enter and update recovery information in claims systems, call tracks and other payment integrity tools.
Prepare and create accurate and timely provider overpayment notification letters and include them with reconciliation back up documentation.
Consistently meet work/performance standards that include payment integrity goals, productivity, quality metrics and monthly savings goals.
Communicate effectively and in a professional manner with internal and external customers regarding all aspects of recovery, claims payment, provider remittances and general recovery processes.
Make and take calls from providers related to overpayment requests/activities.
Research and resolve payment disputes and provide timely follow-up.
Maintain a working knowledge of regulations relevant to payment recovery and claims processing.
Promptly escalate complex issues encountered to the Payment Integrity Manager.
Perform necessary claims adjustments identified in audits when/if needed.
Support User Acceptance Testing (UAT) for large-scale testing projects when/if needed.

Benefits

competitive pay
bonus opportunity
medical, dental, vision, life, AD&D, and disability insurance
health savings account
flexible spending account(s)
lifestyle spending account
employee assistance program
wellness program
discounts
multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.)
strong retirement plan with employer contributions
PTO
Paid State Sick Time
paid holidays
volunteer time
jury duty
bereavement leave