Payment Integrity Specialist

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%

SIU / FWA - Detection and Prevention 30%

Related Responsibilities

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.

WORKING CONDITIONS : Works in a standard office-based environment