Resp & Qualifications
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. This role will be focused on Medicare and Medicaid lines of business.
ESSENTIAL FUNCTIONS:
- 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.
QUALIFICATIONS:
Education Level: Bachelor's Degree in Health Information Management, Data Analytics or equivalent work experience required.Licenses/Certifications Upon Hire Required:
- Certified Professional Coder.
Experience: 3 years year's relevant experience (healthcare claims reimbursement methodologies, claims, and data analysis).
Preferred Qualifications:- Master's Degree in Health Administration, Information Systems, or related field.
Knowledge, Skills and Abilities (KSAs)
- 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.
Salary Range: $53,496 - $106,249
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Department
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
PHYSICAL DEMANDS:
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
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