Massachusetts Veterans Jobs

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.

What You'll Be Doing:

Essential Duties & Responsibilities:

• Assist in the development a stellar payment integrity programs capable of proactively identifying and investigating payment issues and working with stakeholders to develop mitigation strategies to prevent future occurrences, with the ability to review impacts holistically.

• Assist in the development of a comprehensive, strategic roadmap to recover, eliminate, and prevent unnecessary medical-expense spending by reviewing upstream and downstream processes.

• 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.

• Support the execution and maintenance of a corporate claim accuracy program by optimizing pre/post claim editing, auditing, and claim recovery programs.

• Assist in the 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.

• Assist in the 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.

• Assist in developing and maintaining payment integrity policies and procedures.

• Other duties as assigned.

Working Conditions:

• Standard office conditions.

Other:

• Standard office equipment

What We're Looking For:

Required Education (must have):

• Bachelor's Degree or equivalent business experience

Desired Licensing (nice to have):

• Certified Coder a definite plus

Required Experience (must have):

• 7+ years of Healthcare experience, specific to Medicare and Medicaid

• 7+ years progressive experience in medical claims adjudication, clinical coding reviews for claims, settlement, claims auditing and/or utilization review required

• Extensive knowledge and experience in Healhcare Revenue Integrity, Payment Integrity, and Analytics

• 5+ years of Facets Claims Processing System

• Extensive knowledge of health care provider audit methods and provider payment methods, clinical aspects of patient care, medical terminology, and medical record/billing documentation

• Proven 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.

• Advance level experience with Excel and other data systems

Required Knowledge, Skills & Abilities (must have):

• Knowledge and experience of 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 (i.e . Center for Medicare & Medicaid Services (CMS) & MA Medicaid, Correct Coding Initiative (CCI), Medically Unlikely Edits (MUEs) both practitioner and facility, modifier to procedure validation, and other CMS and American Medical Association (AMA) guidelines, etc.)

• Advanced experience of medical terminology and medical coding (CPT, HCPCS, Modifiers) along with the application of Medicare/Massachusetts Medicaid claims' processing policies, coding principals 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

• Understands and recognizes medical and insurance terminology

• 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

Required Language (must have):

• English

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.