Payment Integrity Auditor I/II/III

Claims And Clinical Investigation Specialist Summary: This position is responsible for the accurate and thorough claim and clinical investigation of potential claim payment integrity issues involving all lines of business. This position investigates and remediates claim overpayments, creating data and reporting analytics to analyze data from multiple sources to extract trends, business insights, and to ensure claims payment integrity. Activities are performed through a variety of audits utilizing various systems, data applications, and/or medical records and directed toward reducing costs for the Health Plan, identifying risks and trends, facilitating, and collaborating with stakeholders from all business units on root cause analysis to implement solutions compliant with Provider/Member contracts, as well as internal/external standards set by regulatory and accreditation entities. Essential Accountabilities: Level I Adherence to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates. Ability to use medical records, data reports, researching and investigating for the purpose of detecting and identifying claims payment integrity issues for follow up. Interprets a variety of documents including, but not limited to provider contracts, group benefit structures, Corporate Medical Policies, the AMA CPT Coding Guidelines, HCPCS coding, inter-plan regulations, government policies, as well as diverse regulatory and legal requirements. Utilize analysis and data management using structured data tools. (i.e.: Cognos Analytics, Data Processing Engine, Data Platform, etc.). Reviews, analyzes, and completes audits as assigned; pricing, billing, coding, may include medical necessity, adherence to health plan policies (i.e.: Corporate Medical Policies, CMS local or national coverage determinations (LCD/NCD), administrative policies, clinical edit policies, regulatory agencies etc.) for sound decision on initial, retrospective, or disputed reviews Works collaboratively across departments, consult with Medical Directors where applicable, to ensure the appropriate coding and reimbursement of claims. Identifies and reports to management, providers suspected of fraudulent billing practices and in need of education. Proactively problem solves, investigates, and tactfully brings forward concerns, opportunities, and efficiencies to management and/or business partners with relation to data report analysis and findings. Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs. Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures. Regular and reliable attendance is expected and required. Performs other functions as assigned by management. Level II (in addition to Level I Accountabilities) Demonstrates ability to participate and represent department on internal/external committees. Demonstrates experience mentoring new hires. Performs more complex audits or projects with minimal direction or oversight. Participates and represents in audits, payment methodologies, contractual agreements, with cross-functional teams or with business partners as needed. Level III (in addition to Level II Accountabilities) Broad understanding of multiple cross functional departments and supporting systems. Expertise in reviewing medical coding and medical record review with ability to oversee complex assignments, challenging customers, and highly visible issues. Coordinates and assigns audit assignment to staff working external vendor and/or internal audits. Supports leadership in projects related to divisional/departmental strategies and initiatives. Serves as a Primary Liaison for internal divisions and external recovery vendors. Provides expertise in developing data criteria for converting concepts on relational database audits, as well as to business partners. Acts as a Lead and provides training, guidance, consultation, complex performance analysis, and coaching expertise to team members around methods of continuous quality improvement. Level IV (in addition to Level III Accountabilities) Develops, implements, and monitors action plan for audit requirements or gaps identified. Provides cross-coverage for leadership as needed. Leads outreach to internal department to drive quality improvements throughout the Health Plan initiatives. Conducts medical best practice research, barrier, and root cause analysis to identify and recommend potential member or provider or system interventions. Leads process change and presents results on program activities, overall performance. Collaborates with other Health Plans, government payers, consultants, providers, BCBSA and other health care entities to identify availability and use of best practices relating to quality and performance improvement initiatives, programs, and benchmarks. Minimum Qualifications: All Levels Professional Registered Nurse (RN) with current NYS license or other allied health professional with current NYS license and a minimum of three (3) years of experience in claims auditing, quality assurance, or recovery auditing, in a healthcare setting (i.e., inpatient, outpatient, ancillary, professional) preferred. Bachelor's degree in relevant field preferred. Basic knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology. Basic knowledge of coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates. Requires working knowledge of applicable industry-based standards, and provider reimbursement and coding/billing methodologies. Minimum of two (2) years' experience in healthcare industry preferred (i.e.: experience in Claim Review, Utilization Management, Case Management, Audit, Pharmacy, HEDIS preferred). Must obtain Certified Professional Coder (CPC) or other related certification within eighteen (18) months of hire into department. Demonstrated analytical, organizational, and critical thinking skills. Demonstrated verbal and written communication skills. Level II (in addition to Level I Qualifications) Certified Professional Coder (CPC) or other related certification required. Ability to run and create accurate queries in Cognos Analytics or Data Processing Engine as adjunct to audit research and validation. Intermediate knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology. Intermediate knowledge of coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates. Minimum of two (2) years' experience in healthcare industry required (i.e.: experience in Claim Review, Utilization Management, Case Management, Audit, Pharmacy, HEDIS preferred). Strong analytical, problem solving, and judgement skills. Intermediate knowledge of PC, software, and auditing tools. Demonstrated organizational skills, time management, detail orientation and flexibility with competing priorities. Level III (in addition to Level II Qualifications) Advanced knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology. Advanced knowledge of coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates. Demonstrated leadership skills including mentoring and coaching team members to enhance skillsets. Subject matter expert or consultant to other departments. Advanced proficiency in writing data queries and pulling data reports for ad hoc reports, referred audits, adjustment validation or investigating audit ideas for potential with tools available (i.e.: Cognos Analytics, SAS, Data platform/processing engine, Tableau, Power BI, etc.). Advanced proficiency in PC Skills including Microsoft Office applications (i.e.: Excel, Word, Access, Visio, Outlook, formulas, etc.). Advanced proficiency use of auditing tools (i.e.: ClaimsX10, iHealth, Cognos, Encoder Pro, Clinical Care Advance, Facets, BlueSquared, Data Platform/Processing Engine, etc.). Advanced proficiency in analytical skills, auditing skillset and ability to manage complex assignments, challenging situations, and highly visible issues. Demonstrated project management and presentation skills. Level IV (in addition to Level III Qualifications) Expert knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology. Expert knowledge of coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates. Expert proficiency in writing data queries and pulling data reports for ad hoc reports, referred audits

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