Under the supervision of the Configuration Manager, the Payment Integrity Analyst I will work in conjunction with Business Configuration, Claims, Network, Provider Data, Utilization Management, as well as other operational departments to ensure validation and quality assurance of benefit, contract, reimbursement, and overall financial analysis that arise during the overpayment identification and recovery process.
Identify, analyze, and interpret trends or patterns in complex data sets.
Leverages available resources and systems (both internal and external) to analyze claim information and take appropriate action for payment resolution; documents all activity in accordance with organization policies.
Performs review of claim projects resulting from overpayments or underpayments related to benefits, contracts, and fee schedule defects.
Performs root cause analysis and financial impacts of identified defective claims.
Communicates findings, including trends and recommendations to appropriate leadership.
Research, maintain, test, and create fee schedule tables from data obtained from CMS, Tricare (CHAMPUS), or custom rates into the claims system.
Research, maintain, and create provider reimbursement contract configuration.
Collaborate with and maintain open communication with all departments within CHRISTUS Health to ensure effective and efficient workflow and facilitate completion of tasks/goals.
Follow the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
All other duties assigned by management.
High school diploma or equivalent experience in healthcare claims adjudication, system configuration, and auditing
Strong understanding of healthcare claims data, pricing, and claims editing concepts, including UB04 and HCFA 1500 claim content
Strong working knowledge of health insurance concepts, practices, and procedures, including the understanding of provider payment methodologies and claims processing workflows, from receipt through final adjudication
Strong analytical and research abilities to triage issues and perform reconciliations or data analysis
Working knowledge of Federal and State regulatory rules regarding claims adjudication
Ability to organize and prioritize work to meet deadlines
Strong Microsoft Office application skills, including Microsoft Word and Excel (VLOOKUP, Pivot Tables, Index/Match, Formulas, and creating spreadsheets)
Strong organizational skills and the ability to manage multiple competing projects and deadlines
Ability to think creatively
Excellent written and verbal communication skills
Good judgment, initiative, and problem-solving abilities
Ability to handle and resolve complex issues independently
Knowledge of Commercial, Medicare Advantage, Tricare, and Health Care Exchange programs preferred
Knowledge of CPT/HCPCS, ICD-10 coding, and medical terminology.
Ability to learn new policies and processes based on written material and observation
Ability to establish and maintain professional, positive, and effective work relationships
Demonstrated ability to collaborate effectively and work as part of a team in a fast-changing environment
Experience with interpreting complex provider agreements
Experience in healthcare claims adjudication, system configuration, and auditing.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.