Payer Integrity Specialist

Payer Integrity Specialist

Position Summary

Under the direction of the Director of Reimbursement and Managed Care Contracting, the Payment Integrity Specialist collects and resolves inpatient and outpatient accounts from governmental, commercial, and / or managed care payers through the efficient analysis of payments in accordance with managed care contracts. Captures accurate reimbursements, pursues underpayments, and appeals denials. Reviews, analyzes, and interprets claims for accuracy of charges, payment in accordance to payer contractual agreements and that reimbursement models are appropriate and complete. Administers payer profiling to assist in contractual review and analysis for Med Center Health Managed Care contract negotiations.

Minimum Qualifications

Work Experience

Professional level experience in a healthcare, accounting, finance, or business environment preferred.

Previous experience with third party insurance clams and / or payer contract analysis preferred.

Education

Bachelor’s Degree in Accounting, Finance, Health Care Administration, Business or related degree required.

Master’s degree preferred.

Certifications / Licensure

None required.

Job Specific Performance Standards

The duties listed below are a summary of the major essential functions of this position. The position may require other duties, both major and minor, that are not mentioned, and specific functions may change from time to time.

• Assures payment integrity across Med Center Health for payments from governmental, commercial and managed care payers.
• Utilizes reports from Med Center Health’s payment integrity application to effectively capture accurate reimbursement, pursue underpayments and identify denials.
• Monitors payment integrity application for trends and opportunities to improve payment integrity.
• Reviews, analyzes, and interprets claims to ensure payer contractual agreements and models are appropriate and complete.
• Administers payer profiling to assist in contractual review and analysis for contract negotiations.
• Reviews contracts for compliance with Med Center Health requirements and strategies.
• Coordinates payment integrity statistics and reports status to Director.
• Performs fee schedule review as appropriate and requested.
• Acts a liaison between payers and Med Center Health Finance / Managed Care.

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