Healthcare Claims Integrity Specialist

4 days ago

Albany, New York, United States Innova Solutions Full time
Job Title: Healthcare Claims Integrity Analyst

Join Innova Solutions, a global leader in technology and business transformation, as a Healthcare Claims Integrity Analyst. In this role, you will play a critical part in developing a payment integrity unit that proactively identifies and investigates payment issues, working with stakeholders to develop mitigation strategies to prevent future occurrences.

Key Responsibilities:
  • Assist in the development of a comprehensive, strategic roadmap to recover, eliminate, and prevent unnecessary medical-expense spending by reviewing upstream and downstream processes.
  • Identify overpayment/underpayment opportunities by data mining, investigation, and quality review on benefit and/or provider configuration, rate loads, rate assignments, COB, claims payment logic, etc.
  • Support the execution and maintenance of a corporate claim accuracy program by optimizing pre/post claim editing, auditing, and claim recovery programs.
  • Assist in the development and deployment of mitigation strategies to avoid future overpayments, driving incremental value year over year in both medical and administrative cost savings.
  • Manage the day-to-day financial recovery vendor relationships, validating that identified overpayments are valid and recouped.
  • Assist in the development and implementation of dashboards to monitor performance.
  • Complete and analyze trending reports to identify favorable/unfavorable trends.
  • Analyze departmental performance trends and assist with identifying new opportunities to streamline processes and improve performance of key metrics.
  • Assist in developing and maintaining payment integrity policies and procedures.
Requirements:
  • Bachelor's degree required
  • A minimum of 5 years' working experience within claims in the healthcare or insurance industry
  • Extensive knowledge of health care provider audit methods and provider payment methods, clinical aspects of patient care, medical terminology, and medical record/billing documentation
  • Proven ability to apply quantitative and/or qualitative research and data analysis techniques to improve operational processes
  • Must understand trend information and be familiar with claim coding practices and industry issues in Medicare payment methodologies
  • Advance level experience with Excel, and MS SQL and other data systems are required
Benefits:

Innova Solutions offers a competitive salary range of $60-80K/year, as well as a comprehensive benefits package, including medical and pharmacy coverage, dental and vision insurance, 401(k), health savings account (HSA), flexible spending account (FSA), life insurance, pet insurance, short-term and long-term disability, accident and critical illness coverage, pre-paid legal and ID theft protection, sick time, and other types of paid leaves (as required by law), employee assistance program (EAP).

Innova Solutions is an Equal Opportunity Employer and prohibits any kind of unlawful discrimination and harassment. We are committed to the principle of equal employment opportunity for all employees and to providing employees with a work environment free of discrimination and harassment on the basis of race, color, religion or belief, national origin, citizenship, social or ethnic origin, sex, age, physical or mental disability, veteran status, marital status, domestic partner status, sexual orientation, or any other status protected by the statutes, rules, and regulations in the locations where we operate.

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