Payment Integrity Analyst

Payment Integrity Analyst

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The Payment Integrity Analyst is responsible for executing claims investigation and recovery strategies. This includes analyzing claims data to identify cost containment opportunities across many different claims areas to ensure proper claims payments, as well as conducting in-depth simple to complex claims audits. The Payment Integrity Analyst also works to review and analyze new audit concepts and make recommendations for recoveries and partners with our vendors on additional recovery audits and investigations. The position coordinates with internal business partners in other areas such as Clinical, Contracting, Configuration, Finance, Claims and Provider Relations to ensure efforts are in sync. The role is integral in ensuring claims payment integrity as it supports all recovery efforts for claims processing.

Estimated Hiring Range:

$32.06 - $39.19

Bonus Target:

Bonus - SIP Target, 5% Annual

Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.

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Essential Responsibilities

• Implement new Payment Integrity initiatives as directed by the Payment Integrity Manager and/or Director.
• Partner with others on the Payment Integrity or Claims teams to ensure collaboration, communication and knowledge sharing to maximize team efforts and efficiency.
• Review published Centers for Medicare and Medicaid Services (CMS)/Recovery Audit Contractor (RAC) topics for viability of Care Oregon’s paid claims.
• Review vendor overpayment suggestions for accuracy, adherence to scope, claim recovery activities, new concepts submission and claim sample approval.
• Interact with claims payment vendor and internal departments to discuss system corrections and recommendations regarding claims overpayments.
• Identify and document root causes of overpayments along with remediation recommendations.
• Research and audit simple to complex claims payments including researching tools provided by the Oregon Health Authority (OHA), Medicare billing guidelines, CareOregon’s claims processing policies and procedures and other resources to identify claims overpayments.
• Enter and update recovery information in claims systems, call tracks and other payment integrity tools. 
• Prepare and create accurate and timely provider overpayment notification letters and include them with reconciliation back up documentation.
• Consistently meet work/performance standards that include payment integrity goals, productivity, quality metrics and monthly savings goals.
• Communicate effectively and in a professional manner with internal and external customers regarding all aspects of recovery, claims payment, provider remittances and general recovery processes.
• Make and take calls from providers related to overpayment requests/activities.
• Research and resolve payment disputes and provide timely follow-up.
• Maintain a working knowledge of regulations relevant to payment recovery and claims processing.
• Promptly escalate complex issues encountered to the Payment Integrity Manager.
• Perform necessary claims adjustments identified in audits when/if needed.
• Support User Acceptance Testing (UAT) for large-scale testing projects when/if needed.

Experience and/or Education

Required

• Minimum 3 years’ experience in roles using Medicare and/or Medicaid claims management systems
• Minimum 1 year’ experience performing advanced claims adjustments

Preferred

• 2 years of QNXT experience.
• Certification Experience performing statistical claims analysis in a managed care or health care setting
• Clinical coding certification(s), such as Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Medical Coder (CMC), Certified Coding Associate (CCA), etc.
• Experience with payment integrity programs and/or vendors
• Experience with SQL Server Reporting, or using business intelligence tools (e.g. Tableau) and data frameworks

Knowledge, Skills and Abilities Required

Knowledge

• Working knowledge of claims coding requirements and payment methodologies (e.g. Prospective Payment System (PPS), Medicare Fee Schedules, etc.)
• Knowledge of medical terminology
• Knowledge and skill in using claims management systems, editing software and medical coding

Skills and Abilities

• Solid understanding of complex claims processing and payment integrity/payment policy initiatives including manual pricing, coordination of benefits (COB), adjustments etc.
• Ability to learn state and federal claims and payment integrity regulations
• Ability to use computer programs commonly used for health plan operations
• Statistical, analytical and problem-solving skills
• Strong organization skills
• Strong detail-orientation skills
• Adept at prioritizing work
• Ability to work well under pressure in a complex and rapidly changing environment
• Good spoken and written communication skills
• Ability to present complex information to groups as needed
• Excellent interpersonal skills
• Ability to work independently
• Ability to work effectively and professionally with diverse individuals and groups related to the provision of services
• Ability to present a positive and professional image as a leader and representative of CareOregon
• Advanced skill in Excel helpful
• Ability to learn, focus, understand, and evaluate information and determine appropriate actions
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
• Ability to hear and speak clearly for at least 3-6 hours/day

Working Conditions

Work Environment(s):         ☒ Indoor/Office    ☐ Community      ☐ Facilities/Security                       ☐ Outdoor Exposure

Member/Patient Facing:     ☒ No                        ☐ Telephonic       ☐ In Person

Hazards:  May include, but not limited to, physical and ergonomic.

Equipment:  General office equipment

Travel:  May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.

Work Location: Work from home

We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package.  Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information.

We are an equal opportunity employer

CareOregon is an equal opportunity employer.  The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.