Payment Integrity Analyst

This is a fully remote position, open to applicants in Oregon, +1 more state.

📋 Description

• Implement claims investigation and recovery strategies effectively.

• Evaluate claims data to pinpoint cost containment opportunities and ensure accurate claims payments.

• Conduct audits on claims ranging from simple to complex levels.

• Review and assess new audit concepts, recommending recoveries as necessary.

• Collaborate with vendors on recovery audits and investigations.

• Coordinate efforts with Clinical, Contracting, Configuration, Finance, Claims, and Provider Relations teams.

• Execute Payment Integrity initiatives as directed by the Payment Integrity Manager and/or Director.

• Assess CMS/RAC topics for their applicability against CareOregon paid claims.

• Review vendor suggestions for overpayment for accuracy, adherence to scope, recovery activities, concept submissions, and claim sample approval.

• Discuss system corrections and overpayment recommendations with claims payment vendors and internal departments.

• Identify and document root causes of overpayments and recommend remediation strategies.

• Research claims payments using OHA tools, Medicare billing guidelines, CareOregon policies and procedures, and other relevant resources.

• Input and update recovery information in claims systems, call tracks, and payment integrity tools.

• Draft provider overpayment notification letters accompanied by reconciliation backup documentation.

• Achieve payment integrity, productivity, quality, and monthly savings objectives.

• Communicate with internal and external stakeholders regarding recovery, claims payments, remittances, and recovery processes.

• Manage provider inquiries related to overpayment requests and activities.

• Investigate and resolve payment disputes with prompt follow-up.

• Stay informed about regulations pertinent to payment recovery and claims processing.

• Escalate complex issues to the Payment Integrity Manager as needed.

• Perform claims adjustments identified during audits when necessary.

• Assist with User Acceptance Testing for large-scale testing initiatives as required.

⛳️ Requirements

• A minimum of 3 years of experience in roles utilizing Medicare and/or Medicaid claims management systems.

• At least 1 year of experience in executing advanced claims adjustments.

• 2 years of experience with QNXT is preferred.

• Certification in performing statistical claims analysis in a managed care or health care environment is preferred.

• Clinical coding certification(s) such as CPC, CCS, CMC, or CCA is preferred.

• Experience with payment integrity programs and/or vendors is preferred.

• Familiarity with SQL Server Reporting, business intelligence tools like Tableau, and data frameworks is preferred.

• Proficient understanding of claims coding requirements and payment methodologies, including PPS and Medicare Fee Schedules.

• Knowledge of medical terminology is necessary.

• Skills in using claims management systems, editing software, and medical coding are important.

• Comprehension of complex claims processing and payment integrity/payment policy initiatives, including manual pricing, COB, and adjustments.

• Ability to understand state and federal claims and payment integrity regulations.

• Capability to use commonly utilized computer programs for health plan operations.

• Strong statistical, analytical, and problem-solving skills.

• Excellent organizational and detail-oriented skills.

• Ability to prioritize tasks and work independently.

• Capability to perform well under pressure in a complex and rapidly evolving environment.

• Proficient verbal and written communication skills.

• Ability to convey complex information to groups effectively.

• Strong interpersonal skills.

• Ability to engage professionally with diverse individuals and groups.

• Advanced Excel skills are beneficial.

• Capacity to see, read, and perform repetitive finger and wrist movements for at least 6 hours a day.

• Ability to hear and speak clearly for a minimum of 3–6 hours a day.

🏝️ Benefits

• Bonus - SIP Target, 5% Annual.

• Medical insurance.

• Dental insurance.

• Vision insurance.

• Life insurance.

• AD&D insurance.

• Disability insurance.

• Health savings account.

• Flexible spending account(s).

• Lifestyle spending account.

• Employee assistance program.

• Wellness program.

• Discounts.

• Supplemental benefits including voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, and 529 College Savings.

• Retirement plan with employer contributions.

• PTO.

• Paid State Sick Time.

• Paid holidays.

• Volunteer time.

• Jury duty leave.

• Bereavement leave.

• 401(k) contributions for non-benefits-eligible employees.