As part of the Payment Integrity pre-pay team, the Analyst role will participate with the team in the development and delivery of initiatives focused on claims editing. The Pre-Pay team manages new edits and content as well as the existing edit content using sources (AMA, CPT, AAPC, CMS, etc.). The Analyst role will partner closely with the team around the ongoing development and maintenance of the claims edit platform for professional and facility claims or in collaboration with our other clinical editing vendors. They will collaborate closely with internal stakeholders in the development and maintenance of claims edits and content as it relates to scalability, functionality, and initiatives imperative to growth.
Remote work for this position may be approved based on policy and business considerations. Some states are not eligible for remote work (CA, CT, MA, NJ, NY, Washington D.C.)
Research, identify and propose opportunities for medical cost savings, improves claim auto adjudication rate and payment accuracy.
Primarily focused on clinical editing, content development and maintenance (clinical content and data).
Research, build and test edits to be used in the Claims Editing library.
Test and validate changes made to the content.
Research, analysis, and quality assurance of content for edits within the Claims Editing library.
Utilize strong coding and industry knowledge to research regulatory updates, create and maintain editing content (data used by the edits)
Serve as a subject matter expert for content and edits and provide support where needed.
Works in tandem with internal teams relating to claim edit disputes.
Identify and supply root-cause analysis of edit performance issues.
Collaborates with stakeholder departments to assess and communicate impact to the business for additions, changes, or updates as it relates to content and edit updates.
Create, manage, interpret, and report metrics.
Coordinate with vendors to review findings and identify methods to increase claims payment accuracy and integrity.
Ability to manage and resolve conflicting points of view from providers and internal departments (includes appeals to health plan for Payment Integrity initiatives).
Analyze results of ongoing leakage and prevention monitoring to identify inefficiencies and improve solution effectiveness.
Coordinate and support activities related to vendor contracts. Manage proper controls for vendor invoicing, validation, reconciliations and adjustments. Prepare check requests for vendor payments.
Coordinate with other departments as needed to accomplish cross-departmental projects and/or goals.
Analyze and review initial, subsequent and or final filings to ensure submissions received are covered and eligibility requirements are satisfied per the groups stop loss policy (SPD, stop loss policy, fee disclosure).
Examine claims for stop loss eligibility including verifying stop loss coverage, eligibility (knowledge of plan eligibility requirements including FMLA, MLOA, COBRA).
Required Associate's Degree or equivalent preferably in a health or business related degree
Preferred Bachelor's Degree preferably in a health or business related degree
2 years of relevant experience Health plan operations experience to include end to end claims operations and processes.
Experience with root cause analysis Required
Knowledge of Healthcare Reimbursement methodologies and acceptable billing practices preferred
CES experience preferred
CRT-Professional Coder - AAPC American Academy of Professional Coders Upon Hire preferred Or
CRT-Coding Specialist (CCS) - AHIMA American Health Information Management Association Upon Hire preferred Or
CRT-Coding Specialist, Certified-Physician Based (CCS-P) - AHIMA American Health Information Management Association Upon Hire preferred Or
CRT-Registered Health Information Administrator (RHIA) - AHIMA American Health Information Management Association Upon Hire preferred Or
CRT-Registered Health Information Technician (RHIT) - AAPC American Academy of Professional Coders Upon Hire preferred Or
Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 10 lbs
Waist to Waist > 5 lbs: Seldom up to 10 lbs
Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs
Waist to Overhead > 5 lbs: Seldom up to 10- lbs
Bilateral Carry > 5 lbs: Seldom up to 10 lbs
Unilateral Carry > 5 lbs: Seldom up to 10 lbs
Pushing Force > 5 lbs: Seldom up to 10 lbs
Pulling Force > 5 lbs: Seldom up to 10 lbs
Forward Bend - Standing: Seldom
Forward Bend - Sitting: Occasionally
Trunk Rotation - Standing: Seldom
Trunk Rotation - Sitting: Occasionally
Reach - Above Shoulder: Seldom
Reach - at Shoulder or Below: Seldom
Forceful Grip > 5 lbs: Seldom
Forceful Pinch > 2 lbs: Seldom
Finger/Hand Dexterity: Frequently
Primary LocationSITE - Priority Health - 1239 E Beltline - Grand Rapids
Department NamePH - Payment Integrity - Value and Analysis
Employment TypeFull time
ShiftDay (United States of America)
Weekly Scheduled Hours40
Hours of Work8 a.m. to 5 p.m.
Days WorkedMonday to Friday
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Beaumont Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, gender identity, sexual orientation, age, status as a protected veteran, or status as a qualified individual with a disability.