Payment Integrity Analyst II - Springfield, United States - Health New England

Health New England Springfield, United States

3 weeks ago

Description

Job Description

This position is responsible for maintaining and adhering to internal controls, ensuring compliance with applicable laws and regulations, and following Health New England's entity level policies and procedures. The position is responsible for reporting unethical or fraudulent activity related to business operations and adhering to Health New England's Code of Conduct.

The Payment Integrity Analyst II ensures claim payment integrity through the accurate application of industry pricing and coding by internal and external administration of claims editing and pricing of HNE claims as well as supporting the payment policy development and maintenance process. The Payment Integrity Analyst II supports HNE cost savings efforts through vendor relationships and internal initiatives from conception, implementation and savings monitoring as well as issue identification, root cause analysis and resolution for payment integrity related issues.

Essential Functions:

Cost Savings and Overpayment Recovery Efforts 60%

Responsible for cost savings and overpayment/recovery efforts through data mining, pre-payment solutions, trend analysis and negative balance research and resolution.
Lead efforts for new vendor edit or internal/external cost savings initiatives from concept development, research, vetting through data analysis, testing, post prod monitoring, internal communication, edit savings and performance.
Supports the claims coding software through analysis of current CCI and CMS changes and appropriate application of rules based processing, and claims pricing through correct application of various industry standard fee schedules through 3rd party vendor pricing.
Audits complex hospital and provider contracts compared to claim payment systems in order to confirm appropriate configuration designs and payment methodologies
The Payment Integrity Analyst II serves as a resource to HNE providers and internal departments regarding billing issues specific to payment integrity vendor and inquiries.
Troubleshoots all vendor problems, provider appeals and inquiries to identify improvement areas internally through data analytics collaborating closely with all internal stakeholders to prepare solutions and resolve issues presenting to Management as required.

Payment Policy Support and Development 20%

Support payment policy development and review through the facilitation of workgroup and committee meetings ensuring all policies are up to date and structured process is followed.
Coordinate other payment policies efforts with other internal initiatives including edit development to ensure payment policies align with current system configuration, medical policy or any member/provider documentation.

Special Projects 20%

Supports management with special projects and any cost savings strategic team efforts to achieve payment integrity goals.

Minimum Requirements:

Bachelor's degree with a minimum of 5 years of related experience and/or training

Prior vendor management or process and/or project management experience desired
Prior health claims adjudication experience preferred
Expertise in evaluating vendor performance and holding vendors accountable to SLAs
Excellent communication skills (both verbal and written), with vendor, client, and internal stakeholders
Strong technical writing, critical thinking, problem solving, and conflict management skills
Able to handle multiple assignments/responsibilities simultaneously ensuring appropriate organization and prioritization of such responsibilities
Math and decision-making skills are important for assisting in the selection of vendors that best fit the company's needs

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