Integrity Auditor I​/II​/III

Job Description

This position is responsible for the accurate and thorough claim and clinical investigation of potential claim payment integrity issues involving all lines of business. This position investigates and remediates claim over payments, creating data and reporting analytics to analyze data from multiple sources to extract trends, business insights, and to ensure claims payment integrity. Activities are performed through a variety of audits utilizing various systems, data applications, and/or medical records and directed toward reducing costs for the Health Plan, identifying risks and trends, facilitating, and collaborating with stakeholders from all business units on root cause analysis to implement solutions compliant with Provider/Member contracts, as well as internal/external standards set by regulatory and accreditation entities.

• Adherence to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates.
• Ability to use medical records, data reports, researching and investigating for the purpose of detecting and identifying claims payment integrity issues for follow up. Interprets a variety of documents including, but not limited to provider contracts, group benefit structures, Corporate Medical Policies, the AMA CPT Coding Guidelines, HCPCS coding, inter‑plan regulations, government policies, as well as diverse regulatory and legal requirements.
• Utilize analysis and data management using structured data tools. (i.e.: Cognos Analytics, Data Processing Engine, Data Platform, etc.).
• Reviews, analyzes, and completes audits as assigned; pricing, billing, coding, may include medical necessity, adherence to health plan policies (i.e.:
  Corporate Medical Policies, CMS local or national coverage determinations (LCD/NCD), administrative policies, clinical edit policies, regulatory agencies etc.) for sound decision on initial, retrospective, or disputed reviews
• Works collaboratively across departments, consult with Medical Directors where applicable, to ensure the appropriate coding and reimbursement of claims. Identifies and reports to management, providers suspected of fraudulent billing practices and in need of education.
• Proactively problem solves, investigates, and tactfully brings forward concerns, opportunities, and efficiencies to management and/or business partners with relation to data report analysis and findings.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

• Demonstrates ability to participate and represent department on internal/external committees.
• Demonstrates experience mentoring new hires.
• Performs more complex audits or projects with minimal direction or oversight.
• Participates and represents in audits, payment methodologies, contractual agreements, with cross‑functional teams or with business partners as needed.

• Broad understanding of multiple cross functional departments and supporting systems.
• Expertise in reviewing medical coding and medical record review with ability to oversee complex assignments, challenging customers, and highly visible issues.
• Coordinates and assigns audit assignment to staff working external vendor and/or internal audits.
• Supports leadership in projects related to divisional/departmental strategies and initiatives.
• Serves as a Primary Liaison for internal divisions and external recovery vendors.
• Provides expertise in developing data criteria for converting concepts on relational database audits, as well as to business partners.
• Acts as a Lead and provides training, guidance, consultation, complex performance analysis, and coaching expertise to team members around methods of continuous quality improvement.

• Develops, implements, and monitors action plan for audit requirements or gaps identified.
• Provides cross‑coverage for leadership as needed.
• Leads outreach to internal department to drive quality improvements throughout the Health Plan initiatives.
• Conducts medical best practice research, barrier, and root cause analysis to identify and recommend potential member or provider or system interventions.
• Leads process change and presents results on program activities, overall performance.
• Collaborates with other Health Plans, government payers, consultants, providers, BCBSA and other health care entities to identify availability and use of best practices relating to quality and…