Payment Integrity Analyst

Job not on LinkedIn

🔥 0 minutes ago

🌲 Oregon, Washington – Remote

🌲 Oregon – Remote ☕ Washington – Remote

💵 $32 - $39 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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CareOregon

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1994

🏥 Healthcare

📦 Logistics

🛡️ Insurance

Healthcare • Logistics • Insurance

CareOregon is a community-focused health plan that provides coordinated physical, behavioral, dental and social-support services to Oregon Health Plan members, serving more than 500,000 people. The organization operates provider and member portals, offers care coordination, telehealth, language and tribal services, community grants and outreach, and programs addressing social determinants of health such as housing, nutrition and transportation.

📋 Description

• Execute claims investigation and recovery strategies • Analyze claims data to identify cost containment opportunities and ensure proper claims payments • Conduct simple to complex claims audits • Review and analyze new audit concepts and recommend recoveries • Partner with vendors on recovery audits and investigations • Coordinate with Clinical, Contracting, Configuration, Finance, Claims, and Provider Relations teams • Implement Payment Integrity initiatives directed by the Payment Integrity Manager and/or Director • Review CMS/RAC topics for viability against CareOregon paid claims • Review vendor overpayment suggestions for accuracy, scope adherence, recovery activities, concept submissions, and claim sample approval • Discuss system corrections and overpayment recommendations with claims payment vendors and internal departments • Identify and document overpayment root causes and remediation recommendations • Research claims payments using OHA tools, Medicare billing guidelines, CareOregon policies and procedures, and other resources • Enter and update recovery information in claims systems, call tracks, and payment integrity tools • Prepare provider overpayment notification letters with reconciliation backup documentation • Meet payment integrity, productivity, quality, and monthly savings goals • Communicate with internal and external customers about recovery, claims payments, remittances, and recovery processes • Handle provider calls related to overpayment requests and activities • Research and resolve payment disputes with timely follow-up • Maintain knowledge of regulations relevant to payment recovery and claims processing • Escalate complex issues to the Payment Integrity Manager • Perform claims adjustments identified in audits when needed • Support User Acceptance Testing for large-scale testing projects when needed

🎯 Requirements

• Minimum 3 years’ experience in roles using Medicare and/or Medicaid claims management systems • Minimum 1 year’ experience performing advanced claims adjustments • 2 years of QNXT experience preferred • Certification experience performing statistical claims analysis in a managed care or health care setting preferred • Clinical coding certification(s), such as CPC, CCS, CMC, or CCA, preferred • Experience with payment integrity programs and/or vendors preferred • Experience with SQL Server Reporting, business intelligence tools such as Tableau, and data frameworks preferred • Working knowledge of claims coding requirements and payment methodologies, including PPS and Medicare Fee Schedules • Knowledge of medical terminology • Knowledge and skill in using claims management systems, editing software, and medical coding • Understanding of complex claims processing and payment integrity/payment policy initiatives, including manual pricing, COB, and adjustments • Ability to learn state and federal claims and payment integrity regulations • Ability to use computer programs commonly used for health plan operations • Statistical, analytical, and problem-solving skills • Strong organization and detail-orientation skills • Ability to prioritize work and work independently • Ability to work well under pressure in a complex and rapidly changing environment • Good spoken and written communication skills • Ability to present complex information to groups • Excellent interpersonal skills • Ability to work effectively and professionally with diverse individuals and groups • Advanced Excel skill helpful • Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day • Ability to hear and speak clearly for at least 3–6 hours/day

🏖️ Benefits

• Bonus - SIP Target, 5% Annual • Medical insurance • Dental insurance • Vision insurance • Life insurance • AD&D insurance • Disability insurance • Health savings account • Flexible spending account(s) • Lifestyle spending account • Employee assistance program • Wellness program • Discounts • Supplemental benefits including voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, and 529 College Savings • Retirement plan with employer contributions • PTO • Paid State Sick Time • Paid holidays • Volunteer time • Jury duty leave • Bereavement leave • 401(k) contributions for non-benefits-eligible employees