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Payment Integrity Specialist

2 months ago

New York, New York, United States MetroPlusHealth Full time
Empowering New Yorkers through Healthcare Excellence

MetroPlusHealth is dedicated to delivering exceptional healthcare services to the residents of New York City. As a leading healthcare provider, we are committed to empowering our community through high-quality care and innovative solutions.

About MetroPlusHealth

We provide a comprehensive range of healthcare products and services, including Medicaid Managed Care, Medicare, Child Health Plus, and more. Our network of over 27,000 primary care providers, specialists, and participating clinics ensures that our members receive the best possible care.

Job Summary

The Payment Integrity Analyst will play a critical role in developing and implementing strategies to recover, eliminate, and prevent unnecessary medical-expense spending. This position will work closely with stakeholders to identify and investigate payment issues, develop mitigation strategies, and implement plans to achieve business goals.

Key Responsibilities
  • Assist in the development of a comprehensive payment integrity unit to proactively identify and investigate payment issues.
  • Develop and implement strategies to recover, eliminate, and prevent unnecessary medical-expense spending.
  • Identify overpayment/underpayment opportunities through data mining, investigation, and quality review.
  • Support the execution and maintenance of a corporate claim accuracy program.
  • Manage financial recovery vendor relationships and validate identified overpayments.
  • Develop and implement dashboards to monitor performance and analyze trending reports.
  • Assist in developing and maintaining payment integrity policies and procedures.
Requirements
  • Bachelor's degree required.
  • Minimum of 5 years' experience in claims within the healthcare or insurance industry.
  • Extensive knowledge of healthcare provider audit methods and payment methods.
  • Proven ability to apply research and data analysis techniques to improve operational processes.
  • Advance level experience with Excel and other data systems.

Professional Competencies

  • Strong problem-solving skills.
  • Excellent communication skills.
  • Integrity and Trust.
  • Customer Focus.
  • Functional/Technical skills.
  • Proven track record in building relationships at all levels of the organization.
  • Curious mindset with a focus on process improvement.