Claim Auditor Payment Integrity

The Claim Auditor in Payment Integrity will address problematic and complex audit assignments to identify claim overpayments in accordance with established billing and coding parameters. Claim payment accuracy will be recognized through sound audit review methods and practices, including but not limited to; claim payment evaluation, medical chart review, claim payment data analysis and assessment of established organizational contractual parameters. Independently analyzes, extracts, refines, and interprets claims data for actionable insights. The Auditor uses self-directed, decision making and problem solving that directly impacts financial outcomes and results.

Duties and Responsibilities:

Responsibilities include, but are not limited to:

• Investigate potential over-utilization by performing audits thought pre and post claim payment.
• Initiate and verify claims adjustments, maintain audit documentation, and prepare savings reports.
• Identify new audit areas through data mining and performing sample audits.
• Develops reports and deliverables for management and communicates with all levels of stakeholders.
• Provide recommendations and collaborate with Payment Integrity team on audit outcomes, identified issues, recommended modifications to clinical medical policies, billing and reimbursement guidelines, and online provider manual.
• Serve as contact with all operational areas relevant to Payment Integrity audit decisions.
• Represent company in internal and external meetings/conference calls when needed to discuss audit results or perform coding education.
• Performs 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.

Qualifications

Required:

• Associate's degree or equivalent three (3) years of claim review work experience to equate to the degree
• American Academy of Professional Coder's (AAPC) CPC certification or similar
• Experience in medical records review, claims processing or utilization/case management in clinical practice or managed care organization
• Fundamental knowledge of Medicare/Medicaid Guidelines
• Experience with provider payment methodologies
• Critical thinking and judgment/decision making skills
• Solutions oriented-positive attitude
• Independent problem solving-innovative thinker
• Strong communication skills (written/verbal)
• Excellent Customer Service skills
• Ability to effectively prioritize and execute tasks in a high-pressure environment
• Intermediate to Advanced skills in Microsoft Office (Word, Excel, Outlook)
• Ability to work independently as well as part of a team

Preferred:

• American Academy of Professional Coder's (AAPC) COC and/or CIC
• Data analytics experience
• Knowledge of COGNOS reporting environment

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.