Payment Accuracy Specialist
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Job Description
Payment accuracy specialist auditing healthcare claims for Cotiviti’s payment integrity services. Developing audit concepts, identifying recoveries, and training team members.
Responsibilities:
- Develop new and existing audit concepts and gain client acceptance.
- Train all Specialist levels to execute audit projects.
- Evaluate the effectiveness of audit concepts.
- Audit client data and generate high-quality recoverable claims.
- Conduct and train complex audit projects with limited supervision.
- Mentor, train, and develop less-tenured team members.
- Apply CMS and NAIC guidelines to establish the correct order of liability.
- Use Cotiviti audit tools, Recovery Management System (RMS), client systems, Microsoft Excel, and client applications.
- Identify and define issues, develop criteria, review and analyze evidence, and audit medium and complex reports.
- Perform audits involving Data Mining, Claim Adjudication, Contract Compliance, Provider Billing and Duplicate Payment Reviews, Policy and Reimbursement Analysis, and Quality Assurance.
- Analyze paid claims and identify audit findings, including documentation for training and knowledge sharing.
- Work with Engineering to improve tool and reporting efficiency.
- Update reports, develop and run custom queries, and validate report accuracy.
- Determine recovery likelihood based on client contract terms and prior knowledge.
- Meet productivity, quality, attendance, and audit production standards.
- Respond to claim inquiries and disputes and provide concise factual claim validation and justification.
- Review transaction types, client contracts, vendor agreements, and client data to identify potential overpayments or underpayments.
- Recommend medical policy applications, state and federal statutes, and reimbursement methodologies.
- Onboard new hires and train existing staff on concepts and processes.
- Identify new claim types and expand concepts using research and validation methodologies.
- Recommend new concepts, processes, reports, and tool functionality improvements.
- Collaborate with Engineering to develop new reports and tools.
- Follow Cotiviti policies, procedures, regulatory requirements, HIPAA laws, and data security standards.
Requirements:
- High School Diploma - Required.
- Bachelor’s degree (Preferred) and/or a minimum of at least (4 - 6) year/s related experience in healthcare.
- At least 3 - 4 year/s of Cotiviti experience is recommended for individuals seeking their next opportunity internally.
- Healthcare industry experience, including knowledge of claim adjustments, provider contracts, reimbursement policies and payment integrity.
- Computer proficiency including Microsoft Office (Word, Excel, Outlook, Access).
- Previous SQL experience strongly preferred.
- Excellent verbal and written communication skills.
- Strong interest in working with large data sets and various databases.
- Ability to work well in an individual and team environment demonstrating self–motivation to deliver success.
- Understanding of Cotiviti Core Values, Strategic Pillars, and Operations Disciplines.
- Ability to analyze large volumes of data and identify trends, discrepancies, and anomalies.
- Exceptional attention to detail for accuracy in financial records and audit findings.
- Strong critical thinking and ability to assess complex situations, identify key issues, and propose practical solutions.
- Ability to make informed decisions based on data, regulations, and auditing standards.
- Strong understanding of auditing standards, regulations, and industry best practices.
- Ability to recognize issues requiring further investigation and probe financial records or processes.
- Ability to work effectively as part of an audit team.
- Strong time management skills and ability to manage multiple tasks simultaneously.
- Must be able to provide a dedicated, secure work area.
- Must be able to provide high-speed internet access/connectivity and office setup and maintenance.
Benefits:
- Discretionary bonus consideration
- Medical insurance
- Dental insurance
- Vision insurance
- Disability insurance
- Life insurance
- 401(k) savings plan
- Paid family leave
- 9 paid holidays per year
- 17–27 days of Paid Time Off (PTO) per year, depending on level and length of service
- Overtime pay eligibility for nonexempt employees for hours worked over 40 per week or as required by state law
- Remote work arrangement
- High-speed internet access and office setup/maintenance provided by the team member
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