Payment Integrity Specialist

Qualifications

• BS/BA degree in business, health care, or related field and three (3) to five (5) years of claims editing experience with healthcare payers and/or claims editing software vendors, preferred.
• Nationally recognized coding or billing credential preferred: Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Certified Professional Biller (CPB).
• Experience in claims adjudication and application of National Correct Coding Initiative (NCCI) editing.
• Solid understanding of claims workflow including the interconnection with claim forms.
• Intermediate level proficiency with 837 Electronic data interchange (EDI) mapping for Health Care Financing Administration (HCFA) 1500/UB04.
• Ability to apply industry coding guidelines to claim processes.
• Proven experience reviewing, analyzing, and researching coding issues for payment integrity.
• Ability to troubleshoot and apply root-cause analysis of edit logics not functioning as intended.
• Intermediate level proficiency in Excel (ability to manipulate data using excel functions along with pivot tables, v-look up, etc.).
• Excellent verbal & written communication skills
• Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.
• Home router with wired Ethernet (wireless connections and hotspots are not permitted).
• A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)
• A functioning smoke detector, fire extinguisher, and first aid kit on site.
• Verifiable, clean DMV record and the ability to travel to various locations throughout the U.S. (mainly California and Arizona) up to 10% of the time.

Duties And Responsibilities

• Support the execution and maintenance of payment integrity programs within the department, including pre/post-claim editing, auditing, and recoveries. 
• Collaborate with the IT department to correctly map 837 EDI data to the claims processing system so it can be leveraged for enhanced adjudication, other pass-through processes, and payment integrity program initiatives.
• Provide education and support to claims staff on payment integrity programs, including the detection of fraud, waste, and abuse in medical claims.
• Support the installation of payment integrity programs or Correct Coding Initiative (CCI) edits into the claims processing system.
• Build unit tests to verify the functionality of the edits.
• Identify common error areas that can be made into automated software logic that prevent overpayments from occurring.
• Apply revenue cycle, coding, and billing expertise to interpret policy based on correct coding, billing, and auditing guidelines.
• Develop, implement, and maintain payment integrity policies and procedures.

• Assist in designing and developing a dashboard that will give visibility to leadership on the positive impact of payment integrity programs and initiatives.
• Create new recurring and ad-hoc reports to identify cost avoidance/overpayment opportunities using large data sets on multiple variables.
• Provide data, analysis, and recommendations to management on all findings affecting payments; including provider errors, pricing, systems, and claim processes.
• Identify, analyze, and interpret trends or patterns in complex data sets and report the results to stakeholders to help them make data-driven decisions.

• Integrate industry standard fraud management practices to current claim processing workflows.
• Monitor fraud waste and abuse activities within the Claims Department.
• Leverage claims data for data mining and identification of potential cost savings.
• Analyze departmental performance trends and assist with identifying new opportunities to streamline processes and improve the performance of key metrics.

• Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, be self-accountable, create a positive impact, and be diligent in delivering results.

• Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.  
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.  
• Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit). 
• Maintain a clean DMV record and the ability to travel to locations throughout the U.S. (mainly California and Arizona) up to 10% of the time.  
• All other duties as assigned.

Physical Demands/Work Environment