HEMA- Payer Performance Analyst and Auditor IV

Hema- Payer Performance Analyst And Auditor Iv

Boston Scientific Cardiac Diagnostic Services is an Independent Diagnostic Testing Facility (IDTF) that submits health care claims to both contracted third party insurers under national and local provider contracts and non-contracted insurance entities. The Payer Analytics and Auditing function requires a dual perspective approach that must be performed in sequence and in a fashion that would support any downstream contractual or non-contractual legal considerations. Payer audits can be initiated by the Health Economics and Market Access (HEMA) team to conduct contract performance assessments for new and existing contracts either on a routine basis or in situations of known payer non-compliance, or they may be assigned by the IDTF's Revenue Cycle Management (RCM) team. Payers may also request audits of submitted claims.

Perspective 1 : Internal Contract Performance Review This function assesses contractual terms, conditions, and / or regulatory requirements along with payer policy, identified operational requirements, and billing data to establish full operational compliance within the billing and collecting process.

Perspective 2 : This function assesses claims outcomes to ensure contractual terms, conditions, and / or regulatory requirements were observed by payers as necessary to pay for covered services.

The process to perform audits under Perspective 1 includes a summary overview of claims outcomes to determine if a default audit should become a prerequisite to payer engagement. Default audits are in-depth reviews of claims as necessary to review internal operational processes to prepare evidence of internal operational opportunities for corrective action plans in cooperation with RCM. Default audits are equally required to prepare evidence of internal operational compliance as necessary to prepare evidence for payer presentations under Perspective 2. The process to perform audits under Perspective 2 includes acquiring internal documents demonstrating full compliance when Perspective 1 is not in default as well as claims outcomes documentation to be used as evidence in payer presentations to support appropriate payment or recoup payments that are in arrears.

At Boston Scientific, we value collaboration and synergy. This role allows a hybrid work model, requiring employees to be in our local office at least three days per week.

Relocation assistance is not available for this position at this time.

Boston Scientific will not offer sponsorship or take over sponsorship of an employment VISA for this position at this time.

Your responsibilities include :

• Monitors assigned payers for high-level performance (manually creating scorecards pending automation).
• Produces and circulates payer analytical outcomes data to appropriate internal teams.
• Performs in-depth audits when payers challenge billing practices or rates and reports to HEMA / RCM staff.
• Performs formally assigned payer performance reviews under perspectives 1 & 2.
• Performs formally assigned non-contracted payer performance reviews to support contracting efforts.
• Performs audits of payer clinical and / or contractual policy or operational compliance.
• Performs regulatory audits as required and / or as requested by RCM, HEMA, legal and / or privacy.
• Supports HEMA Centers for Medicare and Medicaid Services (CMS) CERT audits per CERT data validation requirements.
• Performs high-volume data requests or SIU audits from insurers as assigned by HEMA staff.
• Supports assigned practice-requested payer-specific challenges as necessary to support or coordinate coverage issues and / or joint appeals.
• Supports other payer / data projects as assigned by HEMA.

Required qualifications :