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CareFirst BlueCross BlueShield · 2 weeks ago

Payment Integrity Analyst (Remote)

United States

Full-time

Remote

Mid Level

$54K/yr - $108K/yr

3+ years exp

CareFirst BlueCross BlueShield is seeking a Payment Integrity Analyst responsible for conducting research and analysis related to billing requirements and overpayment concepts. The role involves assessing new technology, communicating findings, and implementing improvements to existing processes.

Health CareNon ProfitService Industry

No H1B

Responsibilities

Identifies, develops, and implements new concepts that will target claim overpayment scenarios

Performs analysis on claims, provider data, enrollment data, medical policies, claim payment policies for payment integrity concepts for recovery opportunities

Performs analysis of business unit data and policies, applying a thorough understanding of each line of business specific procedures, to make recommendations to Payment Integrity workgroup and management to reduce and/or eliminate erroneous payment exposure with minimal direction

Identifies and produces root cause analysis when overpayment and cost avoidance concepts are identified to management

Responsible for not only the recovery of the concept but working with each operation to make any necessary technical update to avoid the overpayments moving forward

Tracks and reports progress of current prospective and retrospective cost avoidance/ overpayment recovery concepts

Responsible for carrying out new concepts within the established deadlines with a high level of accuracy

Responsible for resolving any challenges made to the proposed cost avoidance/overpayment concepts throughout the organization working with Provider Network, Provider Contracting, Medical management and policy and Legal

Stakeholder in a cross functional working team to develop and implement new overpayment/cost avoidance concepts

Reviews claims edit concept results for quality assurance and proof of concept validation

Reviews all available sources including federal and state statutes, regulations, provider manuals, Provider contracts, and bulletins for changes to and/or new payment rules

Identifies and documents changes to and/or new payment rules or language in the source document which may be utilized to update existing system edits or new system edits

Qualification

Data AnalysisHealthcare Claims ReimbursementCertified Professional CoderMicrosoft ExcelEffective CommunicationAnalytical SkillsConceptual SkillsProblem-Solving Skills

Required

Bachelor's Degree in Health Information Management, Data Analytics or equivalent work experience required

Certified Professional Coder

3 years relevant experience (healthcare claims reimbursement methodologies, claims, and data analysis)

Strong analytical, conceptual and problem-solving skills to evaluate complex business requirements

Ability to tell the story of the analysis to gain consensus across business units on overpayment items

Effective written and oral communication skills

Ability to review and understand CareFirst medical policies, claim payment policies and provider manuals

Microsoft Excel, Word, and Access

Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence

Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging

Must be eligible to work in the U.S. without Sponsorship