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Company

CorVel Corporation · 9 hours ago

Payment Integrity Analyst III

Fort Worth, TX

Full-time

Remote

Mid, Senior Level

$70K/yr - $108K/yr

3+ years exp

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Responsibilities

Assists with staff communication, providing updates, resolving issues, setting goals and maintaining standards as well as dialogue with team members in efforts to answer their questions and resolve barriers.

Oversees team member work for quality and compliance and communicates deadlines and productivity goals to team members while providing ongoing training and education to staff to ensure policies and procedures are followed.

Verifies and corrects as necessary, the audit work completed by PPI QC analysts and clinical appeal review teams as needed.

Reviews, analyzes, and completes internal audits and/or appeals in accordance with client policy, CMS guidelines and industry standards in clear and professional written communication.

Ability to use clinical judgement and analytical skills to appropriately review documentation submitted for claim audits.

Utilize clinical judgement to appropriately interpret and apply client policies along with CMS guidelines as it relates to reviews done by CERIS such as itemized bill, DRG and/or specialty audits.

Utilize applicable tools and resources to complete internal audits and/or appeals.

Timely completion of internal audits and/or appeals.

Attends Clinical Team Meetings, All Company Meetings, Education Opportunities, Trainings, and other potential meetings.

Additional duties as assigned.

Qualification

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CMS guidelinesClaims processingICD-10 CodingHealthcare revenue cycleLPNLVNRN licensureMicrosoft OfficeMedical bill auditingHealth insurance denialsPayer auditsVendor auditsUtilization review

Required

Must maintain a current LPN, LVN and/or RN licensure

3+ years healthcare revenue cycle or payment integrity experience

3+ years of relevant experience or equivalent combination of education and work experience

Strong understanding of claims processing, ICD-10 Coding, DRG Validation, Coordination of Benefits

Strong understanding of healthcare revenue cycle and claims reimbursement

Proficient in Microsoft Office including Pivot Tables and Database Management

Ability to demonstrate understanding of CMS and commercial payer policy in written and verbal format

Demonstrate ability to manage multiple projects, set priorities and adhere to committed schedule

Strong interpersonal skills and adaptive communication style, complex problem-solving skills, drive for results, innovative

Excellent written and verbal communication skills

Proven track record of delivering concrete results in strategic projects/programs

Strong analytical and modeling ability and distilling data into actionable results

Superb attention to detail and ability to deliver results in a fast paced and dynamic environment

Ability to use clinical judgement and analytical skills to appropriately review documentation submitted for claim audits

Utilize clinical judgement to appropriately interpret and apply client policies along with CMS guidelines as it relates to reviews done by CERIS such as itemized bill, DRG and/or specialty audits

Utilize applicable tools and resources to complete internal audits and/or appeals

Timely completion of internal audits and/or appeals

Attends Clinical Team Meetings, All Company Meetings, Education Opportunities, Trainings, and other potential meetings

Verifies and corrects as necessary, the audit work completed by PPI QC analysts and clinical appeal review teams as needed

Reviews, analyzes, and completes internal audits and/or appeals in accordance with client policy, CMS guidelines and industry standards in clear and professional written communication

Preferred

Preferred experience with health insurance denials and/or appeals, payer audits, or vendor audits

Bachelor’s degree in healthcare or related field preferred

Previous experience in one or more of the following areas required: Medical bill auditing, Experience in the acute clinical areas of facilities in O.R., I.C.U., C.C.U., E.R., Telemetry, Medical/Surgical, OB or L&D, Geriatrics and Orthopedics, Knowledge of worker's compensation claims process, Prospective, concurrent and retrospective utilization review