Payment Integrity Analyst I Job in Irving
Under the supervision of the Configuration Manager, the Payment Integrity Analyst I will work in conjunction with Business Configuration, Claims, Network, Provider Data, Utilization Management, as well as other operational departments to ensure validation and quality assurance of benefit, contract, reimbursement, and overall financial analysis that arise during the overpayment identification and recovery process.
- Identify, analyze, and interpret trends or patterns in complex data sets.
- Leverages available resources and systems (both internal and external) to analyze claim information and take appropriate action for payment resolution; documents all activity in accordance with organization policies.
- Performs review of claim projects resulting from overpayments or underpayments related to benefits, contracts, and fee schedule defects.
- Performs root cause analysis and financial impacts of identified defective claims.
- Communicates findings, including trends and recommendations to appropriate leadership.
- Research, maintain, test, and create fee schedule tables from data obtained from CMS, Tricare (CHAMPUS), or custom rates into the claims system.
- Research, maintain, and create provider reimbursement contract configuration.
- Collaborate with and maintain open communication with all departments within CHRISTUS Health to ensure effective and efficient workflow and facilitate completion of tasks/goals.
- Follow the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
- All other duties assigned by management.
- High school diploma or equivalent experience in healthcare claims adjudication, system configuration, and auditing
- Strong understanding of healthcare claims data, pricing, and claims editing concepts, including UB04 and HCFA 1500 claim content
- Strong working knowledge of health insurance concepts, practices, and procedures, including the understanding of provider payment methodologies and claims processing workflows, from receipt through final adjudication
- Strong analytical and research abilities to triage issues and perform reconciliations or data analysis
- Working knowledge of Federal and State regulatory rules regarding claims adjudication
- Ability to organize and prioritize work to meet deadlines
- Strong Microsoft Office application skills, including Microsoft Word and Excel (VLOOKUP, Pivot Tables, Index/Match, Formulas, and creating spreadsheets)
- Strong organizational skills and the ability to manage multiple competing projects and deadlines
- Ability to think creatively
- Excellent written and verbal communication skills
- Good judgment, initiative, and problem-solving abilities
- Ability to handle and resolve complex issues independently
- Knowledge of Commercial, Medicare Advantage, Tricare, and Health Care Exchange programs preferred
- Knowledge of CPT/HCPCS, ICD-10 coding, and medical terminology.
- Ability to learn new policies and processes based on written material and observation
- Ability to establish and maintain professional, positive, and effective work relationships
- Demonstrated ability to collaborate effectively and work as part of a team in a fast-changing environment
- Experience with interpreting complex provider agreements
- Experience in healthcare claims adjudication, system configuration, and auditing.