Program Integrity Coding & Research Analyst (Health Plan Experienced)
About The Position
The Program Integrity Coding & Research Analyst acts as a Medical Coding subject matter expert for complex coding concerns and serves as the primary coding resource for Program Integrity (PI). This role involves analyzing complex provider claims submissions using knowledge of CPT, ICD10, HCPCS, DRG, and REV coding rules, determining the root cause of provider claim issues, and resolving them by analyzing system configuration, payment policy, and claims data. The analyst will also oversee quality audit programs, research policy impacts, and assist in developing an annual audit plan for high-risk providers. Additionally, the role requires acting as a subject matter expert for claim accuracy audits, leading automation requirements for AI auditing workflows, and collaborating on internal training processes. The analyst will serve as the primary contact for state and market escalations, participate in legal activities, build relationships with essential departments, and provide research and analysis for functional performance enhancements and cost savings. The role also involves identifying and resolving issues with audit capabilities and processes, documenting and reporting on claims reimbursement methodologies, and supporting system change requests. Finally, the analyst will analyze and report on efficiency or financial savings from process improvements and perform other related duties as requested.
Requirements
- Bachelor's degree in Business Administration or related field required
- Seven (7) years of experience in medical coding, to include experience in program integrity coding audit required
- Experience with reimbursement methodology (APC, DRG, OPPS) required
- Certified Professional Coder (CPC) or equivalent billing/coding designation required
- Proficient in Microsoft Office toolset
- Proven ability to establish effective working relationships with stakeholders at all different levels
- Excellent written and verbal communication skills
- Effective identification of business problems, assessment of proposed solutions to those problems, and understanding of the needs of stakeholders
- Ability to work independently and within a team environment
- Ability to multi-task and prioritize work to meet project deadlines
- Effective listening and critical thinking skills
- Flexibility during organizational and/or business changes
- Strong interpersonal and relationship building skills
- Effective problem-solving skills with attention to detail
- Ability to effectively and efficiently lead and/or work within a project team
- Time management skills
- Customer service oriented
- Decision making/problem solving skills
- Ability to develop, prioritize and accomplish goals
- Ability to coordinate and lead cross-functional teams
Nice To Haves
- Equivalent years of relevant work experience may be accepted in lieu of required education
- Five (5) years of experience working with Medicaid policy in developing, analyzing and consulting preferred
- Experience using AI tools and processes preferred
Responsibilities
- Use concepts and knowledge of CPT, ICD10, HCPCS, DRG, REV coding rules to analyze complex provider claims submissions
- Take a lead role to determine root cause of provider claim issues and resolve by analyzing system configuration, payment policy, and claims data
- Oversight of quality audit programs for internal coding validation analysts and produce monthly reports for the managers
- Research policy impacts and communicate those impacts based on audit type and risk to the business
- Assist in the development and implementation of an annual audit plan for providers with high risk for fraud using appropriate risk-based methodology
- Act as subject matter expert for claim accuracy audits for all steps in the audit lifecycle, including disputes
- Lead automation requirements for AI auditing workflows, including QA of policy summaries, checklists and other reference materials used in audits and investigations
- Collaborate in maintaining effective internal training processes
- Serve as primary contact for state and market escalations by providers
- Participate in the preparation of legal activities which includes discovery and trial preparation and testifying as needed
- Build strong working relationships with Markets and departments that are essential for resolving systemic issues and driving process improvements
- Provide critical research and analysis of functional performance, and make recommendations for enhancements, cost savings initiatives and process improvements
- Recognize inconsistencies and gaps in audit capabilities and processes and work collaboratively to resolve the identified issues
- Identify, document, and report on issues with claims reimbursement methodologies
- Support the entry and tracking of system change requests, via appropriate ticketing system, for configuration or other Program and Payment Integrity improvements, act as primary resource and SME in corporate meetings and projects
- Analyze and report measurable changes in efficiency or financial savings related to process improvements
- Perform any other job related duties as requested.
Benefits
- In addition to base compensation, you may qualify for a bonus tied to company and individual performance.
- We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
