Senior Provider Payment Integrity Analyst

Company: Blue Cross & Blue Shield of Rhode Island
Location: West Warwick
Posted on: January 13, 2022

Job Description:

JOB SUMMARY:
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 processes.
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 inconsistencies/overpayments.
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 when necessary.
Perform other duties as assigned.

QUALIFICATIONS:
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 claims processing
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 guidelines.

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 preferred)
Familiarity and ability to interpret hospital/provider contracts
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 areas.
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 policies
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