Payment Integrity Analyst III

The Payment Integrity Analyst (Team Lead) assists with leading the Policy and Payment Integrity (PPI) team while maintaining the regular duties and responsibilities of this role which is accurately reviewing pre and post pay claim audits based on client, policy, industry standards and / or CMS guidelines.

The Team Lead must also be knowledgeable of the application of client policy and industry standards within reviews conducted by CERIS including but not limited to itemized bill review, professional review, hospital outpatient; trend analysis of internal auditing, appeals of pre and post payment claims, and any other claim or record that requires quality review to determine claim accuracy; assist with development of internal quality assurance measures based on client policy and industry guidelines; perform quality assurance reviews; assist in researching and implementing best practices related to payment policy, and / or policy initiatives; researching various healthcare policies.

This is a remote position.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES :

• Assists with staff communication, providing updates, resolving issues, setting goals and maintaining standards as well as dialogue with team members in efforts to answer their questions and resolve barriers.
• Oversees team member work for quality and compliance and communicates deadlines and productivity goals to team members while providing ongoing training and education to staff to ensure policies and procedures are followed.
• Verifies and corrects as necessary, the audit work completed by PPI QC analysts and clinical appeal review teams as needed.
• Reviews, analyzes, and completes internal audits and / or appeals in accordance with client policy, CMS guidelines and industry standards in clear and professional written communication.
• Ability to use clinical judgement and analytical skills to appropriately review documentation submitted for claim audits.
• Utilize clinical judgement to appropriately interpret and apply client policies along with CMS guidelines as it relates to reviews done by CERIS such as itemized bill, DRG and / or specialty audits.
• Utilize applicable tools and resources to complete internal audits and / or appeals.
• Timely completion of internal audits and / or appeals.
• Attends Clinical Team Meetings, All Company Meetings, Education Opportunities, Trainings, and other potential meetings.
• Additional duties as assigned.

KNOWLEDGE & SKILLS :

EDUCATION / EXPERIENCE :

PAY RANGE :

CorVel uses a market based approach to pay and our salary ranges may vary depending on your location. Pay rates are established taking into account the following factors : federal, state, and local minimum wage requirements, the geographic location differential, job-related skills, experience, qualifications, internal employee equity, and market conditions. Our ranges may be modified at any time.

For leveled roles (I, II, III, Senior, Lead, etc.) new hires may be slotted into a different level, either up or down, based on assessment during interview process taking into consideration experience, qualifications, and overall fit for the role. The level may impact the salary range and these adjustments would be clarified during the offer process.

Pay Range : $70,016 $108,106

A list of our benefit offerings can be found on our CorVel website : CorVel Careers | Opportunities in Risk Management

In general, our opportunities will be posted for up to 1 year from date of posting, or until we have selected candidate(s) to fulfill the opening, whichever comes first.

About CERIS

CERIS, a division of CorVel Corporation, a certified Great Place to Work Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities. We embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).

A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w / Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off.

CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.

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