Integrity Analyst

Payment Integrity Analyst

The Payment Integrity Analyst is responsible for executing claims investigation and recovery strategies. This includes analyzing claims data to identify cost containment opportunities across many different claims areas to ensure proper claims payments, as well as conducting in-depth simple to complex claims audits. The Payment Integrity Analyst also works to review and analyze new audit concepts and make recommendations for recoveries and partners with our vendors on additional recovery audits and investigations.

The position coordinates with internal business partners in other areas such as Clinical, Contracting, Configuration, Finance, Claims and Provider Relations to ensure efforts are in sync. The role is integral in ensuring claims payment integrity as it supports all recovery efforts for claims processing.

Estimated Hiring Range: $32.06 - $39.19 Bonus Target:
Bonus - SIP Target, 5% Annual

• Implement new Payment Integrity initiatives as directed by the Payment Integrity Manager and/or Director.
• Partner with others on the Payment Integrity or Claims teams to ensure collaboration, communication and knowledge sharing to maximize team efforts and efficiency.
• Review published Centers for Medicare and Medicaid Services (CMS)/Recovery Audit Contractor (RAC) topics for viability of Care Oregon’s paid claims.
• Review vendor over payment suggestions for accuracy, adherence to scope, claim recovery activities, new concepts submission and claim sample approval.
• Interact with claims payment vendor and internal departments to discuss system corrections and recommendations regarding claims over payments.
• Identify and document root causes of over payments along with remediation recommendations.
• Research and audit simple to complex claims payments including researching tools provided by the Oregon Health Authority (OHA), Medicare billing guidelines, Care Oregon’s claims processing policies and procedures and other resources to identify claims over payments.
• Enter and update recovery information in claims systems, call tracks and other payment integrity tools.
• Prepare and create accurate and timely provider over payment notification letters and include them with reconciliation back up documentation.
• Consistently meet work/performance standards that include payment integrity goals, productivity, quality metrics and monthly savings goals.
• Communicate effectively and in a professional manner with internal and external customers regarding all aspects of recovery, claims payment, provider remittances and general recovery processes.
• Make and take calls from providers related to over payment requests/activities.
• Research and resolve payment disputes and provide timely follow-up.
• Maintain a working knowledge of regulations relevant to payment recovery and claims processing.
• Promptly escalation complex issues encountered to the Payment Integrity Manager.
• Perform necessary claims adjustments identified in audits when/if needed.
• Support User Acceptance Testing (UAT) for large-scale testing projects when/if needed.

• Minimum 3 years’ experience in roles using Medicare and/or Medicaid claims management systems.
• Minimum 1 year’ experience performing advanced claims adjustments.
• Preferred 2 years of QNXT experience.

• Performing statistical claims analysis in a managed care or health care setting.
• Clinical coding certification(s), such as Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Medical Coder (CMC), Certified Coding Associate (CCA), etc.
• Experience with payment integrity programs and/or vendors.
• Experience with SQL Server Reporting, or using business intelligence tools (e.g. Tableau) and data…