Payment Integrity Analyst II

Network Health's success is rooted in its mission to create healthy and strong Wisconsin communities. It drives the decisions we make, including the people we choose to join our growing team. Network Health is seeking a Payment Integrity Analyst II. This position performs recurring and ad-hoc audits of intermediate complexity to help ensure that claims are paid in accordance with established criteria.

Responsibilities include auditing high dollar claims and working with various external Payment Integrity partners to validate and apply pre and post-payment audit findings to claims. Role requires advanced claims, configuration, reimbursement, enrollment, and other skilled monitoring activities for all lines of business. This role analyzes current business practices to identify potential issues leading to claim leakage, document findings and partner with departments regarding findings and trends discovered from monitoring processes.

Duties:

• Audit high dollar claims to ensure payment accuracy (e.g. edits, authorization, pricing/reimbursement, OOP, benefits)
• Review health care claims of intermediate to high complexity to ensure payment accuracy
• Be able to identify overpayments or underpayments on claims
• Shares findings and ideas in a meaningful and easy way to understand
• Makes recommendations for process efficiencies and/or claim cost savings based on claim audit findings
• Maintains and updates tracking databases and/or files to support monitoring activities
• Performs analysis of results to identify potential or existing issues and collaborates with internal departments regarding audit findings and trends to identify root causes; identifies opportunities for changes and/or improvements to audit activities; enhance efficiencies and savings to the plan
• Assists with the implementation and ongoing evaluation of Payment Integrity policies and procedures.
• Provide and discuss audit results with the Payment Integrity manager and other Payment Integrity team members
• Ensures that desk level procedure (DLP) documents are kept current
• Identifies provider education opportunities and assists in the development of those provider resources, if requested by contracting/provider relations
• Investigates unusual billing patterns and refers to the Special Investigations Unit (SIU) as appropriate
• Research and respond to coding questions from internal and external clients
• Manage day-to-day Payment Integrity vendor activities
• Actively participates in shared accountability and commitment for departmental and organization-wide results. Supports departmental/team goals and objective.

Requirements:

• Associates degree or four years of equivalent work experience required
• 3 or more years of experience working in health care or health insurance required
• 2 or more years working in an auditing or claim payment accuracy focused role required.
• 2 or more years of experience with claims processing/monitoring, system configuration, pharmacy, enrollment, finance and/or appeals and grievance related position required.
• 1 year working in Payment Integrity

Skills:

• Medical coding experience and/or certification (AAPC or AHIMA) strongly desired, but not required
• Strong understanding of government-regulated medical plans and programs (CMS, Medicare, Medicaid, ACA, etc.)
• Knowledgeable about common healthcare payment methodology criteria (ICD-10, CPT, HCPCS, Revenue Codes, DRG, Percent of Charge, Case Rate, Per Diem, outliers, pass throughs, etc.)
• Ability to trend identified issues and collaborate with business units to influence process improvements
• Demonstrates highly developed organizational and problem-solving skills, strong analytical skills, and attention to detail

We are proud to be an Equal Opportunity Employer who values and maintains an environment that attracts, recruits, engages and retains a diverse workforce.