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Payment Integrity Specialist

Payment Integrity Specialist

Health New EnglandBrockton, MA, United States
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SUMMARY : The Payment Integrity / Special Investigation Unit (PI / SIU) Specialist is responsible for managing the audit functions across all lines of business as well as all fraud, waste and abuse (FWA) activities for HNE. The PI / SIU Specialist is responsible for developing, executing and overseeing a comprehensive risk based audit & FWA plan with the objectives of detecting, investigating, preventing and resolving (through prosecution or otherwise if necessary) cases of health care fraud, waste and abuse; auditing daily operational activities, safeguards, processes and procedures to validate they are functioning properly. The role will be responsible for implementing policies that meet or exceed government requirements; to minimize financial, legal and customer service risk exposures. This individual must be able to effectively present information and establish clear understanding and buy-in.

ESSENTIAL FUNCTIONS :

Audit 50%

  • Participate in configuration design review sessions, and evaluate level of complexity and identify potential exposure in contract / configuration set-up.
  • Audit complex hospital and provider contracts compared to claim payment system in order to confirm appropriate configuration including but not limited to; audit for correct claim coding, validation of billed services, consistent application of payment rules
  • Identify opportunities for the establishment of audit activities in support of HNE's critical business functions and coordinate audit activities with other departments
  • Provide feedback and process improvement recommendations to appropriate health plan operation departments and participate in workgroups / committee meetings and process improvement solutions as required.
  • Coordinate corrections with claims and membership areas.
  • Communicate information, observations and findings to other departments in order to prevent inappropriate payment of claims.
  • Communicate and coordinate reviews with physician office staff and distribute correspondence related to the review. Assess review data to determine areas of improvement for follow up physician training and communication.
  • Maintain continuous accurate and complete documentation for department specific, ongoing, and situational audits and recommend revisions / improvements to audit functions
  • Perform audits on-site, electronically or in the field.

Payment Integrity 20%

  • Research, interpret and provide clear direction to the stakeholder departments on new and changing code requirements, covered and non-covered determinations and payment schedules and provide fact-based recommendations.
  • Provide leadership and collaborate on internal and external audits.
  • Develop financial models and tools, including cost-benefit analysis, claims trend analysis.

    • SIU / FWA - Detection and

    Prevention 30%

  • Develop and perform a comprehensive FWA monitoring program for government programs (Medicare and Medicaid)
  • Investigates cases of known, reported or suspected fraud, waste and abuse
  • Gather, analyze, evaluate facts and evidence and draw sound conclusions
  • Determine whether fraud (intent) or abuse (without defined intent) was the outcome utilizing sound conclusions
  • Assist with identifying opportunities for improvement and correction actions designed to strengthen internal controls, correct underlying problems that may result in fraud, waste or abuse and prevent further misconduct
  • Assist with oversight of auditing services from outside vendors and HNE business partners.
  • Manage and investigate incidents / leads as assigned related to areas of regulatory, compliance, fraud, waste and abuse and violation of policy and procedure. Report issues to Compliance Manager and Director of Payment Integrity / SIU
  • Develop reporting for FWA and compliance activities

    • Related Responsibilities

  • Stays abreast of current coding issues and changes, reviews medical coding trends and identifies potential training needs.
  • Ensure compliance with regulatory requirements and standards. Understand regulatory environment and ensure contractual compliance with federal and state requirements (Medicare, Medicaid).

    • MINIMUM REQUIREMENTS :

    Bachelor's degree in Business, Healthcare Administration or related field with more than 3 years claims auditing experience; or more than 3 years experience in Fraud, Waste &

    Abuse preferably in an HMO or MCO; or an equivalent combination of education and experience.

  • Experience in Medicare compliance
  • CPC and or CPC-H certification preferred
  • CPMA certification preferred
  • Understanding of Commercial insurance business practices and government health insurance products (Medicare& Medicaid).
  • Proficiency with healthcare coding (CPT / HCPCS, ICD-9 and ICD-10 & Revenue Codes)
  • Working knowledge and experience in cross-functional business segments and their integrated influences and relationships
  • Highly effective research, writing, and communication skills
  • Skilled with Microsoft Office Suite (Access, Word, Excel, PowerPoint)
  • Good problem solving skills
  • Excellent organizational skill
  • Strong attention to detail
  • Excellent critical thinking, and analysis skills
  • Ability to understand and interpret government health insurance laws and regulations
  • Ability to present an unpopular opinion
  • Ability to work well independently or with others
  • Ability to work well with both internal and external customers

    • WORKING CONDITIONS : Works in a standard office-based environment

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    Payment Specialist • Brockton, MA, United States