Prospect Medical Systems ยท 12 hours ago
Claims Payment Integrity Analyst
Orange, CA
Full-time
Remote
Mid Level
3+ years exp
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Responsibilities
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.
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.
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.
Qualification
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Required
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
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
Company
Prospect Medical Systems
With approximately 9,000 physicians to serve our 660,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Arizona, Texas, and Rhode Island.
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
Jim Brown, MBA, MPH
Chief Executive Officer
Lily Kam
Chief Financial Officer
Company data provided by crunchbase
