Payment Integrity Coding and Operations Analyst

Altais

3d•$75,000 - $90,000

About The Position

Are you looking to join a fast-growing, dynamic team? We’re a collaborative, purpose-driven group that’s passionate about transforming healthcare from the inside out. At Altais, we support one another, adapt quickly, and work with integrity as we build a better experience for physicians and their patients. As a Payment Integrity Coding and Operations Analyst within the Payment Integrity team, you will help us ensure honest claims are paid accurately, minimize losses, and protect those most vulnerable. You will be responsible for operationalizing payment integrity claim controls with a portion identifying providers who are not appropriately following protocol. You will review medical records and claims on both a pre and post pay basis and prepare claim payment recommendations based on your review. You will focus on Medical Record and Edit Review: Collaborate with the Payment Integrity team on healthcare fraud, waste, and abuse investigations Conduct provider claim review, prepare review summaries with recommendations and proper citations and resources Review medical records and claims on a pre and post pay basis for PI cases involving fraud, waste, or abuse Support investigation and clinical discussions with external parties including but not limited to: providers, regulators, law enforcement, etc. Apply industry, state, and federal regulations and guidelines Assess findings to detect patterns of fraud, waste and abuse Make accurate claim decisions based on policies, payment rules, and coding guidelines Payment Integrity Vendor Relationship Management: Subject matter expert in Payment Integrity vendor relationships Engage and align payment integrity vendors and all related internal teams and external vendor partners Growth & Optimization: Drive execution of initiatives related to payment integrity growth and optimization. Operationalize business and/regulatory requirements, including payment integrity process improvement and work for developing prospective claim editing while utilizing clinical coding and payment policies.

Requirements

Bachelor’s degree or equivalent experience.
5+ years of experience in a position processing medical claims coding reviews
3+ years of experience conducting or managing comprehensive research to identify billing abnormalities, questionable billing practices, irregularities, and fraudulent or abusive billing activity
2+ years of experience working in a government, legal, law enforcement investigations, health care managed care, and/or health insurance environment
Intermediate to advanced skills in Microsoft product suite
Proven critical thinker
Certified Professional Coder (CPC)

Responsibilities

Collaborate with the Payment Integrity team on healthcare fraud, waste, and abuse investigations
Conduct provider claim review, prepare review summaries with recommendations and proper citations and resources
Review medical records and claims on a pre and post pay basis for PI cases involving fraud, waste, or abuse
Support investigation and clinical discussions with external parties including but not limited to: providers, regulators, law enforcement, etc.
Apply industry, state, and federal regulations and guidelines
Assess findings to detect patterns of fraud, waste and abuse
Make accurate claim decisions based on policies, payment rules, and coding guidelines
Subject matter expert in Payment Integrity vendor relationships
Engage and align payment integrity vendors and all related internal teams and external vendor partners
Drive execution of initiatives related to payment integrity growth and optimization.
Operationalize business and/regulatory requirements, including payment integrity process improvement and work for developing prospective claim editing while utilizing clinical coding and payment policies.