Payment Integrity Claims Editing Analyst
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Job Description
Analyst providing analytical, technical, and problem resolution support to Payment Integrity Claims Editing System. Working with internal partners to ensure adherence to standards and regulations.
Responsibilities:
- Work with internal and external partners to identify and validate new provider concepts and scenarios through analysis of paid claims data, review of internal payment and medical policies, and any other pertinent information to support determination(s).
- Independently evaluate and analyze submitted claims to ensure the concepts/scenarios aligns with Capital book of business.
- Includes but not limited to: Research and analysis of applicable provider contract terms and rates
- Analysis of member benefits and utilization
- Analysis of overarching administrative regulations (Federal, State, BCBSA, etc.)
- Analysis of appropriate provider coding and billing practices and coding guidelines.
- Serve as a department lead for to present new edit concepts and issues to internal business areas.
- Communicate status updates verbally and in writing to impacted internal business areas.
- Identify new edit or solutions, projects risks, and contingencies.
- Conduct root cause analysis and identify process improvement opportunities.
- Build strong working relationships with internal and external customers.
- Summarize verbally and in writing, advanced analytical research, including claim analysis, which is understandable to the intended audience.
- Facilitate meetings including preparing agendas, minutes, and other documentation as needed.
- Communicate delays, risks, and impacts to both management and business areas.
- Ongoing business evaluation of vendor updates, but not limited to LCD reviews, and knowledge base updates (edits).
Requirements:
- Minimum three years’ working experience within claims in the healthcare or insurance industry.
- Proficient in conducting cost benefit analysis techniques.
- Strong knowledge of and experience with ICD-10, DRG, CPT/HCPCS coding guidelines.
- Experience with and knowledge of multiple provider reimbursement and pricing methodologies (DRG, SPC, OFS, POC, Global Pricing, Per Diem, etc.)
- Bachelor’s Degree preferred in one of the following: Business Administration, Health Planning and Administration, Information Systems, Computer Science, and/or Current Medical Coding certification or obtained within one (1) year of hire date.
Benefits:
- Medical, Dental & Vision coverage
- Retirement Plan
- Generous time off including Paid Time Off
- Holidays
- Volunteer time off
- Incentive Plan
- Tuition Reimbursement
- and more.
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