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Payment Integrity Specialist I

4 months ago

Springfield, United States Health New England Full time
Job DescriptionJob Description

This position is responsible for maintaining and adhering to internal controls, ensuring compliance with applicable laws and regulations, and following Health New England’s entity level policies and procedures. The position is responsible for reporting unethical or fraudulent activity related to business operations and adhering to Health New England’s Code of Conduct.


Summary: Provide a brief summary of the purpose of this role. Include the role’s primary responsibility, its impact on end results, and the degree of freedom to act.


The Payment Integrity Analyst I is responsible for researching and identifying overpayment recovery and the recovery of stagnant negative balances of professional, facility and ancillary claims through pre and post pay effort. In addition, the Payment Integrity Analyst I supports claim payment integrity through the accurate application of industry pricing and coding by internal and external administration of claims editing and pricing of HNE claims as well as supporting the payment policy development and maintenance process. The Payment Integrity Analyst I supports HNE cost savings efforts through internal initiatives as well as issue identification, root cause analysis and resolution for payment integrity related issues.


Essential Functions: List in order of importance the essential duties and responsibilities of this role, and estimate the percentage of time spent on each. Include management and supervisory responsibilities, if any.

Negative Balance and Overpayment Recovery – 50%

• Support pre and post claim payment activities working with team and claims staff to facilitate retractions and cost avoidance through pre/post-payment claim efforts.

• Work Payment Integrity submitted inquiries from business areas to help in issue resolution.

• Reviews all negative balance overpayment recovery cases to determine action to be taken.

• Generates overpayment demand letters within established timeframes.

• Liaison to recovery vendor – CBAS.

• Documents all overpayment recovery activities in savings trackers.

• Tracks recovery efforts and update PI savings reporting.

Recovery Process Improvements - 20%

• Identifies trends resulting from recovery inquiries and recommends solutions to reduce volume of phone inquiries and improve procedures.

• Supports efforts for cost savings and overpayment/recovery through data mining, pre-payment solutions, trend analysis and negative balance research and resolution.

• Acts as a liaison to resolve recovery issues and works on potential process improvements in cooperation with ASO, Finance and Contracting Departments.

• Identifies system and process flaws and recommends areas for improvements.


Special Projects -30%

• Serves as a resource to HNE providers and internal departments regarding billing issues specific to payment integrity vendor and inquiries.

• Supports data mining efforts to identify pre and post cost savings opportunities for recovery based on claim payment analysis against HNE policy and contracting provisions.

• Supports payment policy process and efforts to ensure policies are up to date and reflect current HNE policy and contracting provisions.

• Services as coding Subject matter expert in the review of claims and medical records for appropriate coding and payment as well as payment integrity coding related inquiries including provider appeals and member services inquiries


Minimum Requirements: State the specific knowledge, skills, abilities, and experience required to perform the essential functions listed above. Include particular degrees, licenses, certifications, etc. if they are a minimum requirement for the job.


• High school diploma or equivalent and 5 years of medical claims processing experience in a managed care setting to include complex claims adjustments and research; or an equivalent combination of education and experience.

• Considerable knowledge of DRG, ICD-10, CPT-4 and HCPCS coding

• Good knowledge of medical terminology

• Familiarity with applicable HMO, PPO Commercial and Medicare regulations

• Good ability to perform in a fast paced environment

• Good organizational and prioritizing skills

• Considerable ability to deal with providers in a manner which shows sensitivity, tact and professionalism

• Excellent written and verbal communication skills

• Proficiency with Microsoft Office products