Payment Integrity Representative

This is a fully remote position, open to applicants in Iowa, +5 more states.

📋 Description

• Review, maintain, and evaluate records of underpayments as well as managed care contracts.

• Ensure that Sanford receives payments in line with contract stipulations and optimize reimbursement while adhering to compliance protocols.

• Develop, document, and manage standard operating procedures in OneNote pertaining to claim adjudication business rules.

• Analyze reimbursement methods, fee schedules, payment classification systems, payer Remark and Reason codes, and remittance advice.

• Oversee appeals related to underpayments and overpayments in accordance with internal guidelines.

• Conduct reimbursement analysis and testing categorized by payer, and assess trends in managed care issues.

• Review managed care activities within the system to ensure payment compliance with contracts and payer regulations.

• Identify operational errors, investigate coverage setup challenges, and provide guidance as necessary.

• Recognize and report enrollment concerns for new payers.

• Examine patterns of claim variances and systemic issues within payer claim systems.

• Educate and share pertinent information with internal departments and payers.

• Communicate with payers to pinpoint underpayment issues and compile findings for resolution.

• Assist billing and finance teams with analysis and reporting to support operational decision-making.

• Foster relationships with management, staff, departments, and payers while facilitating negotiations and achieving consensus.

⛳️ Requirements

• An associate degree in healthcare or a business-related field is required, or a minimum of three years of prior experience in the healthcare revenue cycle can be considered in place of formal education.

• Proficiency in working with Excel spreadsheets is mandatory.

• At least two years of previous healthcare experience with knowledge of healthcare reimbursement is preferred.

• Standard productivity requirements must be met prior to transitioning to a home-based role.

• Director approval is necessary to transition to a home-based position if productivity criteria are met with less than one year of experience in a Sanford office.

• Capability to analyze managed care contracts, fee schedules, reimbursement/payment classification systems, remittance advice, and payer Remark and Reason codes.

• Ability to investigate claims, identify payment discrepancies and systemic payer issues, analyze trends, and interpret intricate contracts.

• Proficient in negotiation, consensus-building, communication, and relationship management.

• Capacity to thrive in a fast-paced, high-volume, and dynamic environment.

🏝️ Benefits

• Flexible work arrangements, including the opportunity to transition to a home-based position upon meeting productivity standards.

• Supportive team environment.

• Day shift schedule.

• 40 scheduled hours per week.