Payment Integrity Recovery Partner

Payment Integrity Recovery Partner #24-575
Administrative Support
Why This Role is Important to Us Position Summary: Working under the direction of the Sr. Director, TPA Management and Claims Compliance, the Payment Integrity (PI) Recovery Analyst will assist in the development of a strategic roadmap to recover, eliminate, and prevent unnecessary medical expense spending and support the execution for a comprehensive claim accuracy program. The individual will optimize pre/post claims auditing and claim recovery programs that will drive incremental value year over year. The PI Recovery Analyst will employ use of analytics, trends, competitor benchmarking, and outcomes to continually identify savings opportunities, develop mitigation strategies to avoid future overpayments/underpayments, and implement plans to achieve business goals.
Supervision Exercised: No, this position does not have direct reports.
Required Education (must have): Bachelor's Degree or equivalent business experienceRequired Experience (must have): 7+ years of Healthcare claims auditing experience, specific to Medicare and Medicaid7+ years progressive experience in medical claims adjudication, clinical coding reviews for claims, settlement, claims auditing and/or utilization review requiredExtensive knowledge and experience in Healthcare Revenue Integrity, Payment Integrity, and Analytics5+ years of Facets Claims Processing SystemExtensive knowledge of health care provider audit methods and provider payment methods, clinical aspects of patient care, medical terminology, and medical record/billing documentationProven ability to apply quantitative and/or qualitative research and data analysis techniques to improve operational processes.Must understand trend information and be familiar with claim coding practices and industry issues in Medicare payment methodologies.Advanced level experience with Excel and other data systemsWhat You'll Be Doing: Lead development of stellar payment integrity programs capable of proactively identifying and investigating payment issues and working with stakeholders to develop mitigation strategies to prevent future occurrences.Responsible for auditing and identifying complex claims projects, internal claim audits, and change auditing styles processes that target CCA's PI Financial goals.End to end project management, including concept development, finding concepts that haven't been worked, and researching concepts to strengthen PI savings.Identify and monitor changing patterns of competition, recommend changes while presenting to CCA's leadership for future PI initiatives.Lead a comprehensive, strategic roadmap to recover, eliminate, and prevent unnecessary medical-expense spending by reviewing upstream and downstream processes.Utilize claims analytics to uncover payment accuracy opportunities through knowledge of standard payment methodologies including Prospective Payment Systems (IPPS/OPPS), fee for service, Groupers, RUG, etc.Identify overpayment/underpayment opportunities by data mining, investigation, and quality review on benefit and/or provider configuration, rate loads, rate assignments, COB, claims payment logic, etc.Identify areas of opportunity for Payment Integrity Intelligence by staying up to date on current events, changes in regulatory requirements and market trends.Support the execution and maintenance of a corporate claim accuracy program by optimizing pre/post claim editing, auditing, and claim recovery programs.Lead development and deployment of mitigation strategies to avoid future overpayments, driving incremental value year over year in both medical and administrative cost savings.Manage the day-to-day financial recovery vendor relationships, validating that identified overpayments are valid and recouped.Lead development and implementation of dashboards to monitor performance.Complete and analyze trending reports to identify favorable/unfavorable trends.Analyze departmental performance trends and assist with identifying new opportunities to streamline processes and improve performance of key metrics.Develop processes, frameworks, trainings, templates/forms, standard operating procedures, strategic plans to ensure CCA's PI annual and monthly financial goals are met.Develop and maintain payment integrity policies and procedures.Other duties as assigned.Required Knowledge, Skills & Abilities (must have): Knowledge and experience of claims auditing, claim operations, health care reimbursement, public health care programs and reimbursement methodologies (Medicaid and Medicare).Medical Coding, Compliance, Payment Integrity and Analytics.Direct and relevant experience with HCFA/UB-04 claims management, coding rules and guidelines, and evaluating/analyzing claim outcome results for accurate industry standard coding logic and policies.Advanced experience of medical terminology and medical coding (CPT, HCPCS, Modifiers) along with the application of Medicare/Medicaid claims' processing policies, coding principles and payment methodologies.Ability to work cross-functionally to set priorities, build partnerships, meet internal customer needs, and obtain support for department initiatives.Ability to plan, organize, and manage own work; set priorities and measure performance against established benchmarks.Ability to communicate and work effectively at multiple levels within the company.Customer service orientation; positive outlook, self-motivated and able to motivate others.Strong work ethic; able to solve problems and overcome challenges.Knowledge of CPT, ICD10, HCPCS or other coding structures are required.Knowledge of UB-04s, CMS 1500 forms, and itemized statements.Demonstrated ability to establish and manage performance and outcome metrics.Strong overall Microsoft Office skills with an emphasis on Excel skills.Excellent collaboration and communication skills with the ability to partner effectively across the organization and with external partners.Understanding of individualized complex care plans.Strong strategic thinker and tactical performer.Experience mentoring less experienced auditors.Strong project management skills with the demonstrated ability to handle multiple projects.Ability to establish and maintain positive and effective work relationships with internal staff, external vendors, and state and federal agencies.Proven skills and judgment necessary for independent decision-making.Excellent organizational, time-management and problem-solving skills.Ability to influence decision making.Strong problem-solving skills.Excellent communication skills, both written and verbal.Integrity and Trust.Customer Focus.Functional/Technical skills.Proven track record in building and fostering relationships at all levels of the organization.Work well in a fast-paced environment, both independently and partnering with other business areas to achieve objectives.Curious mindset with a focus on process improvement.
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