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Resp & Qualifications
The Payment Integrity Analyst is responsible for conducting research and analysis and reviewing mandates, provider manuals, bulletins, and other sources as needed to identify new overpayment concepts, as well as, validate all prospective and retrospective overpayment results. The Payment Integrity Analyst will lead the effort in identifying new overpayment and cost avoidance concepts by proposing these concepts to the SI and SBU management. The Payment Integrity Analyst will also be responsible for assessing and implementing any new technology needed to stand up new processes, as well as contributing new ideas for improving existing processes.
PRINCIPAL ACCOUNTABILITIES: Under the direction of Manager, SI Payment Integrity, the principle duties and responsibilities include, but are not limited to, the following:
Identifies, develops, and implements new concepts that will target claim overpayment scenarios for each of CareFirst SBU’s. Performs analysis on claims, provider data, enrollment data, medical policies, claim payment policies for payment integrity concepts for recovery opportunities. Performs analysis of business unit data and policies, applying thorough understanding of each line of business’s specific procedures, to make recommendations to SI Management and SBU Management to reduce and/or eliminate erroneous payment exposure with minimal direction. Identifies and reports back to SI and SBU Management root cause analysis when overpayment and cost avoidance concepts are identified. Responsible for not only the recovery of the concept but working with each SBU to make any necessary technical update to avoid the overpayments moving forward.
Tracks and reports progress of current prospective and retrospective cost avoidance/ overpayment recovery concepts. Responsible for carrying out new concepts within the established deadlines with a high level of accuracy. Responsible for resolving any challenges made to the proposed cost avoidance/overpayment concepts throughout the organization working with Provider Network, Provider Contracting, Medical management and policy and Legal. Stakeholder in a cross functional working team to develop and implement new overpayment/cost avoidance concepts.
Reviews claims edit concept results for quality assurance and proof of concept validation.
Reviews all available sources including federal and state statutes, regulations, provider manuals, Provider contracts, and bulletins for changes to and/or new payment rules.
Identifies and documents changes to and/or new payment rules or language in the source document which may be utilized to update existing system edits or new system edits.
• Bachelor’s Degree in Health Information Management, Data Analytics or equivalent work experience required.
• Minimum 3+ year's relevant experience (healthcare claims reimbursement methodologies, claims, and data analysis)
• Strong analytical, conceptual and problem-solving skills to evaluate complex business requirements.
• Ability to “tell the story” of the analysis to gain consensus across business units on overpayment items
• Ability to take tips, industry concepts and internal ideas and turn them in to a potential cost savings idea or algorithms
• Effective written and oral communication skills
• Ability to demonstrate in-depth knowledge of medical terminology, CPT coding.
• Ability to review and understand CareFirst medical policies, claim payment policies and provider manuals.
• Ability to work proficiently with Microsoft Excel, Word, and Access
• Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
• Master’s Degree in Health Administration, Information Systems, or related field
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
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