Payment Integrity Analyst - 40 hrs/wk, 1st shift
Blanchard Valley Regional Health Center

Job Info

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PURPOSE OF THIS POSITION

The purpose of the Payment Integrity Analyst is to ensure that all claims are paid at contracted rates by researching and resolving payment variances for all applicable payers, with the goal of maximizing reimbursement for the services provided by Blanchard Valley Health System. This position is responsible for understanding healthcare contracting terms and requirements to address underpayments, overpayments, and denials in accordance with regulatory and contractual obligations. This includes contract content review, application of appropriate contract terms and fee schedule(s), and a thorough understanding of the requirements of the Government and Non-Government payment policies & payer contracts. The Payment Variance Analyst will be responsible for identifying trends and reporting issues to the appropriate leadership for the purpose of enforcing Payer Contract Compliance. In addition, this position is held accountable to adhere to all policies, procedures, and applicable laws; including metrics related to productivity and quality. This position works both independently and as a part of the Denials Prevention Analyst team, as well as with other teams throughout the health system.

JOB DUTIES/RESPONSIBILITIES

• Duty 1:Pursue additional payments from payers in a timely and accurate manner, which maximizes reimbursement and recovers funds in compliance with payer regulations and the department's policies and procedures.
• Duty 2Reviews historical payment information to determine accuracy of reimbursement, reviews potential payment variances, and identifies true discrepancies. Collaborates with various departments to compile worklists that highlight common causes of underpayments.
• Duty 3:Consistently utilizes and accurately interprets various contracts. Resolves payment disputes with payers by following appeal protocols and processes. Stays current on payer reimbursement policy changes and contract updates. Calculates expected reimbursement based upon payer contracts and reimbursement policies.
• Duty 4: Consistently identifies and pursues the collection of money due or refunds owed on inappropriately paid accounts; ensures all functions related to underpayments, overpayments, and denials support the team goals and objectives as well as Blanchard Valley Health Systems financial performance objectives.
• Duty 5: Work closely by way of problem solving with peers and leaders to address payer underpayment, overpayment, and denial issues or changes that directly impact the accounts receivable. Works closely with the managed care department to resolve identified payment patterns which result in underpayments, overpayments, or denials.
• Duty 6: Maintains dashboard to report KPI's on false positive underpayments, and/or the contract accuracy rate as identified in Contract Manager.
• Duty 7: Manages, verifies, and monitors refund requests and overpaid accounts for appropriate payors. Works with the appropriate departments to resolve any discrepancies in which corrections need to be made to resolve the overpayment. Ensures disputes are filed within a timely manner. Validates that overpayments are recouped.
• Duty 8: Track overpayments to identify trends to be used in education and process improvement. Resolves claims with balances that are in an EOB variance status.
• Duty 9: Serves as a resource for department, patients, and payers seeking to resolve questions and/or concerns regarding payment variances.
• Duty 10: Participates in daily huddles, idea board meetings, staff meetings, and meeting with external departments for managing daily improvements.
• Duty 11: Communicate in a professional manner with patients, representatives from third party payor organizations, provider relations, contract management, other internal customers, and co-workers, etc. in a manner to achieve revenue cycle department AR goals.
• Duty 12: Identify opportunities for system and process improvement and submit to management.
• Duty 13: Ensures that services are provided in accordance with state and federal regulations, organization policy, and compliance requirements.

REQUIRED QUALIFICATIONS

• Associate's degree in a related field including, but not limited to, health information, business, healthcare finance or related clinical profession or requires 3+ years' experience from which comparable knowledge and abilities have been acquired.
• Three (3)+ years Healthcare Revenue Cycle experience.
• Three (3)+ years of insurance billing and reimbursement processes, including understanding of cash posting, explanation of benefits (EOB), remittance advice, and denial codes.
• CPC or CCS Certification or obtained within the first 12 months of hire.
• An understanding of payor contract terms, fee schedules, and payer reimbursement guidelines. Understands and recognizes medical and insurance terminology.
• Knowledge of revenue codes, CPT/APC/HCPCS, ICD/DRG coding, NCCI, HIPAA, and other applicable concepts. Knowledge of CMS 1500 forms, UB-04's, remittance advice, and itemized statements.
• Knowledge of revenue cycle workflows and systems used within the Revenue Cycle such as Cerner, Trisus, Forvis, Quadax, KaiNexus, 3M, Experian, etc.
• Regulatory compliance and reimbursement methodologies knowledge required. Ability to research, review, analyze, and interpret Federal, State and Local billing regulations required.
• Ability to compile, analyze and effectively present data and complex information in an informative and meaningful way to a variety of audiences, including leadership.
• Ability to manage complex issues and manage multiple tasks/projects. Excellent organizational and time management skills; detail oriented and follow through. Self-directed.
• Strong problem-solving, research, and analytical skills
• Positive service-oriented interpersonal and communication (written and verbal) skills required. Ability to effectively present and interact with all levels of the organization, including senior leadership.

PREFERRED QUALIFICATIONS

• Bachelor's degree in a healthcare related field
• Direct professional and/or facility denial management experience
• CHRI certification
• CPFSS certification

PHYSICAL DEMANDS

This position requires a full range of body motion with intermittent walking, lifting, bending, squatting, kneeling, twisting and standing. The associate will be required to walk for up to one hour a day, sit continuously for six hours a day and stand for one hour a day. The individual must be able to lift twenty to fifty pounds and reach work above the shoulders. The individual must have good eye-hand coordination and fine finger dexterity for simple grasping tasks. The individual must have excellent verbal communication skills to perform daily tasks. The associate must have corrected vision and hearing in the normal range. The individual must be able to operate a motor vehicle for business travel and community involvement.

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