Payment Integrity Analyst

Job not on LinkedIn

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $24 - $32 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

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Modivcare

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 2017

🏥 Healthcare

⚕️ Healthcare Insurance

🚗 Transport

💰 $525M Post-IPO Debt on 2024-07

Healthcare • Healthcare Insurance • Transport

Modivcare is a company that focuses on simplifying the experience of living with complex healthcare needs by providing a comprehensive suite of supportive care solutions. They specialize in non-emergency medical transportation, personal care, and virtual & remote patient monitoring. Modivcare works closely with Medicaid Plans, State Agencies, Medicare Advantage, SNP Plans, health systems, healthcare professionals, and transportation providers, ensuring that members receive necessary health services. Through innovative technology and data-driven strategies, they address social determinants of health by offering services like quality transportation, chronic care management, meal delivery, and in-home assistance, aimed at optimizing patients' health outcomes and improving their overall experience.

📋 Description

• Review submitted NEMT claims for fraud, waste, abuse, billing discrepancies, duplicate billing, overpayments, and other payment integrity concerns • Analyze claims, trip documentation, authorizations, provider records, contracts, and supporting documentation to determine claim validity • Recommend claim approval, denial, adjustment, or recovery based on findings and established guidelines • Document claim reviews, findings, and recommendations accurately in designated systems • Identify trends, patterns, and anomalies indicating improper billing or potential fraudulent activity • Refer appropriate cases to the Special Investigations Unit (SIU) • Ensure claim determinations comply with contractual obligations, client requirements, company policies, and federal and state regulations • Collaborate with Claims Operations, SIU, Compliance, Provider Relations, and other internal departments • Assist with improving payment integrity processes, controls, and audit methodologies • Maintain productivity, quality, and turnaround-time expectations • Prepare reports and communicate findings to leadership • Maintain confidentiality and comply with HIPAA and privacy and security requirements • Participate in ongoing payment integrity, fraud prevention, and NEMT operations training • Perform other duties as assigned

🎯 Requirements

• High school diploma required • Bachelor's degree from an accredited college or university preferred • Four (4) years of directly related experience in claims analysis, Payment Integrity, SIU, or FWA investigations • Strong analytical and investigative skills with exceptional attention to detail • Knowledge of payment integrity principles and fraud, waste, and abuse detection techniques • Understanding of NEMT claims processing, provider billing practices, and supporting trip documentation • Ability to analyze large volumes of claim and operational data • Ability to exercise sound judgment and make well-supported claim recommendations • Strong written and verbal communication skills • Proficiency in Microsoft Office Suite, particularly Excel • Ability to manage multiple priorities and meet deadlines • Demonstrated integrity, professionalism, and commitment to confidentiality • Experience with NEMT claims and operations preferred • Experience with Medicaid managed care programs preferred • Knowledge of NEMT provider billing practices, trip documentation requirements, and authorization processes preferred • Experience using claims management systems and data analysis tools preferred • Professional certification related to fraud examination, investigations, auditing, or payment integrity preferred

🏖️ Benefits

• Medical, Dental, and Vision insurance • Employer Paid Basic Life Insurance and AD&D • Voluntary Life Insurance (Employee/Spouse/Child) • Health Care and Dependent Care Flexible Spending Accounts • Pre-Tax and Post-Tax Commuter and Parking Benefits • 401(k) Retirement Savings Plan with Company Match • Paid Time Off • Paid Parental Leave • Short-Term and Long-Term Disability • Tuition Reimbursement • Employee Discounts (retail, hotel, food, restaurants, car rental and much more!)