Senior Provider Payment Integrity Analyst
Company: Blue Cross & Blue Shield of Rhode Island
Location: West Warwick
Posted on: January 13, 2022
The Senior Payment Integrity Analyst will independently conduct
complex, in-depth analysis of claim payments and its methodology,
identifying trends and patterns, to ascertain cost
avoidance/overpayment recovery opportunities. Apply root cause
analysis to design and develop solutions to payment integrity
opportunities/issues, and coordinate implementation efforts with
internal stakeholders as well as vendor(s) and providers as
applicable. Track and report progress of prospective and
retrospective cost avoidance/overpayment recoveries. Carry out new
recovery concepts within the established deadlines with a high
level of accuracy. Resolve any challenges made to the proposed cost
avoidance/overpayment concepts throughout the organization,
including but not limited to Provider Relations, Provider
Contracting, Medical/Payment Policy and Legal teams. Ensure medical
claims, records, and other documentation essential to claims
submission and reimbursement is in compliance with state and
federal guidelines, provider contracts, BCBSRI policy, national
coding guidelines and industry standards.
ESSENTIAL JOB FUNCTIONS:
Conduct a thorough analysis of all medical claims for adherence to
state and federal guidelines, provider contracts, BCBSRI policy,
national coding guidelines and industry standards.
Review, research, and interpret medical record documentation,
claims data, contractual guidelines, payment methodologies and
system adjudication to identify trends and patterns in complex
claims payment data that result in recovery opportunities.
Create new recurring and ad-hoc reports to identify cost
avoidance/overpayment opportunities using large data sets on
multiple variables. Provide data, analysis, and recommendations to
management on all findings affecting payments, including policy,
contract issues, provider errors, pricing, systems, and claim
Build strong stakeholder relationships and deliver solutions that
meet stakeholders' expectations; establish and maintain effective
relationships - both internal as well as external.
Provide ongoing feedback to key internal stakeholders with the goal
of improving internal payment control and reducing payment
Perform audit peer review analysis periodically to assure quality
of results and consistency in content, analytics and adherence to
department policies and procedures.
Develop written reports in accordance with reporting standards.
Ensure that all audit findings, exceptions and proposed adjustments
to work papers/communication documents are well defined and
explained or included in reports.
Manage appeals process with providers and third-party arbitrators
Perform other duties as assigned.
Minimum Education and Experience:
A combination of education and experience
Coding Certification (CPC, CCS, CPMA or equivalent)
Five to seven plus years of experience in medical claims review or
Proven analytic expertise using Microsoft Excel and Access,
database query capabilities, and ability to evaluate data at all
levels of detail
Experience with manipulating large datasets
Experience concisely communicating complex analyses to gain
consensus across departments on overpayment items
Experience turning internal recommendations and industry concepts
into potential cost saving.
Experience with medical terminology, claim audit procedures,
provider contracts, claims processing procedures and
Preferred Education, Additional Qualifications and Experience:
Five to seven plus years of experience in quantitative or
statistical analysis (preferably in health care)
Experience using PC SAS (preferably Enterprise Guide SAS), SQL,
and/or Business Objects.
Knowledge of diagnostic related groups (DRG's) and American
Hospital Association Official Coding Guidelines
Knowledge of Current Procedural Terminology (AAPC Certification
Familiarity and ability to interpret hospital/provider
Familiarity with medical claims reimbursement
Required Knowledge, Skills, and/or Abilities:
Knowledge of medical claims data
Knowledge of managed care practices
Knowledge of Correct Coding Initiative (CCI) guidelines
Knowledge of all claim forms and coding types, including UB-04, CMS
1500, ICD-9 and ICD-10, HCPC, revenue codes, NDC coding, HIPPA,
HEIDIS, and NCQA.
Demonstrated ability to constructively and sensitively provide
feedback to providers regarding federal and state coding, medical
documentation and compliance guidelines, audit results and risk
Audit skills and the ability to interpret and apply Federal and
State regulations, coding and billing requirements.
Demonstrated ability to review analytical, data and audit findings
to identify coding trends and risk areas.
Ability to interpret contract reimbursement schedules and
Strategic and critical thinking skills
Strong problem-solving skills
Keywords: Blue Cross & Blue Shield of Rhode Island, Warwick , Senior Provider Payment Integrity Analyst, Professions , West Warwick, Rhode Island
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