Associate, Reimbursement Analyst II

Summary

We are seeking a talented individual who is responsible for full claim overpayment analysis. Assists with identification of claims paid in error and audits paid claims data through multiple tools and methods by utilizing state and federal manuals/regulations, billing and reimbursement policies and practices as well as identifying changes in system edits or new system edits. 

Your role in our mission

• Utilizes CMS, State and Client billing and reimbursement policies, client reimbursement practices (through review of manuals/regulations and meetings with stake holders to identify through tried and true queries claim overpayments. Identifications will need to be performed with limited oversight 

• Participates in the review of paid health insurance claims and member eligibility information to uncover claims overpayment trends 

• Works with data miners, clinical staff, and stakeholders to identify overpaid claims for each client Use internal and client systems for audit tracking and findings. 

• Organizes, documents, and communicates results. Collaborates with IT resources as needed 

• Ensures individual and departmental goals are consistently met or exceeded, in collaboration with other team members and management. 

• Contributes new ideas for improving existing audit processes and audit queries. Works cohesively with the ideation team and internal clients 

• Providing feedback to ideation team for trending of provider billing and claims processing by researching client policy and data to reveal new overpayment recovery opportunities 

• Assists in the identification of new audit concepts 

• Compiles supporting documents, sample claims and audit approval request form for client approval prior to implementing new audit concept 

• Research industry clinical standards and guidelines 

• Tracks, and follows-up on recoveries 

• Excellent verbal and written communication skills 

What we're looking for

• 4-6 years of healthcare reimbursement experience such as provider contract development, healthcare claims analysis, medical billing/coding, patient accounting, claims auditing, and/or revenue cycle improvement required 

• Must have demonstrated experience and knowledge of healthcare claims processing (Medicaid, Medicare, Commercial Insurance), including ICD-9-CM codes, HCPCS codes, CPT codes, DRGs, physician billing, etc. 

• Experience in healthcare auditing, reviewing and validating the accuracy of claims data and accuracy of claims payment preferred 

• Experience applying published healthcare guidelines such as CMS regulations and coding guidelines to healthcare claims data, Recovery audit experience a plus preferred 

• Excellent analytical skills (required) Excellent time management skills (required) 

• Ability to develop, organize, and maintain project plans and agendas 

• Knowledge of Medicaid, Medicare and Commercial policy and reimbursement or equivalent healthcare experience (preferred) 

What you should expect in this role

• Remote in All USA Locations