Claims Payment Integrity Analyst

Job Description

We are seeking a detail-oriented and analytical Claims Analyst to join our healthcare team. The ideal candidate will act as the primary vendor relationship owner with Prospect Medical Systems (PMS) external 3rd party payment integrity partners and uses technology and data mining, to detect anomalies in claims data to identify overpayments. Leverages vendor solutions along with reporting tools for professional and institutional claims analysis. Contributes to the investigations of fraud waste and our financial recovery. The Pl Analyst work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. Responsibilities will focus on preventing unnecessary payments to providers and partnering with cross-departmental teams to recover overpayments when they occur. Furthermore, Pl Analy-ml complete analyses and prepare disclosure materials while interacting and building partnerships with Prospect Medical Systems' Operations, and information technology teams, along with external vendors. The role will include responsibility for owned IPAs, MSO clients, risk types for multi-state areas, and all lines of business. will continually identify areas of opportunity for increased efficiency, accuracy.

Responsibilities

Payment Integrity Oversight (Implementation, Quality, and Savings Tracking)

• Oversight of multiple payment methodologies and billing guidelines including but not limited to, CMS, Medicare Provider Reimbursement Manual, NCCI, MUE, LDCs, NCDs, National Uniform Billing Committee, AMA, DRG, APG, APDRG, NDC, etc.
• Research, document, and analyze multi-faceted data with statistical, financial, and clinical emphases.
• Identify data trends, develop programs to solve problems, and assist in presenting and implementing recommendations and solutions.
• Act as a liaison with 3rd party vendors, including managing the relationship, auditing, executing UAT on new rule sets, making recommendations for improvement, and providing updates to management.
• Tracks and trends edits, savings with month-over-month reporting ensuring ROI projections.
• From a Pl perspective makes recommendations regarding the accuracy of claim payments and process improvements
• Communication with Management informing of any discrepancies in claim adjudication, contract provisions, and or rates schedules.
• Develop appropriate recommendations and suggestions based on analysis and collaborate with management in the development of action plans where required. Identify improvement opportunities to increase claim accuracy. Completely understands Vendor solutions, source files, and tables used in the creation of meaningful reports via Excel & Power Bl.
  
  

Documentation, Training & Development

• Ensure adherence to all Legislative, Regulatory, and Contractual requirements as it relates to Payment Integrity systems and claim adjudication.
• Develop appropriate recommendations and suggestions based on data analysis and collaborate with management in the development of action plans where required. Identify improvement opportunities to increase claim auto adjudication & accuracy.
• Identify training needs/ gaps for the team and ensure timely and effective training is imparted to all team members
• Independently create and develop communication to internal and external parties on regulatory claims rules and industry changes
  
  

Collaboration

• Build and maintain productive & collaborative intradepartmental relationships with department leads (Claims, UM, Pharmacy, Eligibility, Configuration, Encounters, Performance Programs, Accounting/ Finance, Recovery, Compliance, Configuration, Network Management, IT Ops, etc.) to enable effective and timely problem/improvement identification & resolution and drive operational excellence
• Liaison to internal departments and external provider groups on escalated Payment Integrity claims issues, focusing on dispute and root cause analysis.
• Collaborate with Claims Leadership to communicate root cause analysis, solutions and prevention plans.
• Collaborate with the Configuration and IT Teams to continuously improve upon Payment Integrity system configuration/ rules set up for accurate and effective claims adjudication.
• Recommend changes for system design, rules, and workflows affecting Claims processing.
• Proactively contribute to Claims testing/ audit strategy development and provide timely feedback based on day-to-day findings
  
  

Qualifications

Required Education/Experience

• Bachelors in Health Administration or 3+ years experience in Managed Care and Claims Operations in IPA setting; or equivalent combination of education and experience required.
• 3+ years of experience as a medical claims analyst, adjuster, or senior examiner
• Extensive knowledge of claims processing guidelines, including, perspective payment systems, DRG payment systems, comprehensive coding edits, Medicare guidelines, and Medi-Cal guidelines
  
  

Preferred Education/Experience

• Certified Professional Coder, CPC license
• Master's Degree in HealthCare Administration or equivalent. Microsoft Power Bl, SQL experience
• Athena, IDX System experience
• 2+ years of supervisory experience in the healthcare industry
  
  

"Location-Based Pay Adjustment"

About Us

With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS.