Senior Payment Integrity Analyst

Found in: Talent US C2 - 2 weeks ago

Smithfield, United States Neighborhood Health Plan of Rhode Island Full time

Duties and Responsibilities

Responsibilities include, but are not limited to the following:

Develop and maintain departmental dashboards Assist Director with coordination of interdepartmental working sessions to advance collaboration and the goals of the Payment Integrity department Coordinate with vendors to design and propose and implement solutions that increase claims payment accuracy and integrity Develop detailed implementation plans to manage and track solution administration Develop and maintain policies and procedures for the Payment Integrity department Review claims, auto-adjudicated claims based on provider and health plan contractual agreements and claims processing guidelines. Follows all internal processes and procedures to ensure claims audit activities are handled in accordance with company policies and procedures. Coordinate prevention implementation with recovery initiatives, as necessary Help draft and facilitate deployment of prevention solution components such as policy changes, operations training content, customer service training and education materials, and provider communications Design approaches, mechanisms, and report requirements to track prevention savings. Maintain tracking tools. Analyze results of ongoing leakage and prevention monitoring reports to identify inefficiencies and improve solution effectiveness Define and manage proper controls for vendor invoicing including validation, reconciliations, and adjustments and support invoice approvals Collaborate with trainers and claims management regarding necessary training for staff based on findings Conduct analysis to support internalization of vendor algorithms to increase medical expense savings. Provide insight for new claim scenario creation, validation, deployment, and monitoring. Prepare and issue audit reports which include audit findings, scores and corrective actions Identify root cause of errors and work with internal and external departments for resolution Assist external departments with research of claims processing issues Serve as mentor to junior Analysts Participate in external departments audits when requested Other duties as assigned Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents

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