What are the responsibilities and job description for the Payment Integrity Analyst position at MetroPlusHealth?
Empower. Unite. Care.
MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.
About NYC Health Hospitals
MetroPlus Health provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health Hospitals, the largest public health system in the United States, MetroPlus Health 's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus Health has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
Position Overview
The Payment Integrity (PI) Analyst will assist in the development of a strategic roadmap to recover, eliminate, and prevent unnecessary medical-expense spending and support the execution for a comprehensive claim accuracy program. The incumbent will optimize pre / post claim editing, auditing, and claim recovery programs that will drive incremental value year over year. The PI Analyst will employ use of analytics, trends, competitor benchmarking, and outcomes to continually identify savings opportunities, develop mitigation strategies to avoid future overpayments / underpayments, and implement plans to achieve business goals.
Job Description
- Assist in the development a stellar payment integrity unit capable of proactively identifying and investigating payment issues and working with stakeholders to develop mitigation strategies to prevent future occurrences, with the ability to review impacts holistically.
- Assist in the development of a comprehensive, strategic roadmap to recover, eliminate, and prevent unnecessary medical-expense spending by reviewing upstream and downstream processes.
- Identify overpayment / underpayment opportunities by data mining, investigation, and quality review on benefit and / or provider configuration, rate loads, rate assignments, COB, claims payment logic, etc.
- Support the execution and maintenance of a corporate claim accuracy program by optimizing pre / post claim editing, auditing, and claim recovery programs.
- Assist in the development and deployment of mitigation strategies to avoid future overpayments, driving incremental value year over year in both medical and administrative cost savings.
- Manage the day-to-day financial recovery vendor relationships, validating that identified overpayments are valid and recouped.
- Assist in the development and implementation of dashboards to monitor performance.
- Complete and analyze trending reports to identify favorable / unfavorable trends.
- Analyze departmental performance trends and assist with identifying new opportunities to streamline processes and improve performance of key metrics.
- Assist in developing and maintaining payment integrity policies and procedures.
Minimum Qualifications
Professional Competencies
LI-Hybrid
MPH50
