Payment Integrity Specialist

SUMMARY : The Payment Integrity / Special Investigation Unit (PI / SIU) Specialist is responsible for managing the audit functions across all lines of business as well as all fraud, waste and abuse (FWA) activities for HNE. The PI / SIU Specialist is responsible for developing, executing and overseeing a comprehensive risk based audit & FWA plan with the objectives of detecting, investigating, preventing and resolving (through prosecution or otherwise if necessary) cases of health care fraud, waste and abuse; auditing daily operational activities, safeguards, processes and procedures to validate they are functioning properly. The role will be responsible for implementing policies that meet or exceed government requirements; to minimize financial, legal and customer service risk exposures. This individual must be able to effectively present information and establish clear understanding and buy-in.

ESSENTIAL FUNCTIONS :

Audit 50%

• Participate in configuration design review sessions, and evaluate level of complexity and identify potential exposure in contract / configuration set-up.
• Audit complex hospital and provider contracts compared to claim payment system in order to confirm appropriate configuration including but not limited to; audit for correct claim coding, validation of billed services, consistent application of payment rules
• Identify opportunities for the establishment of audit activities in support of HNE's critical business functions and coordinate audit activities with other departments
• Provide feedback and process improvement recommendations to appropriate health plan operation departments and participate in workgroups / committee meetings and process improvement solutions as required.
• Coordinate corrections with claims and membership areas.
• Communicate information, observations and findings to other departments in order to prevent inappropriate payment of claims.
• Communicate and coordinate reviews with physician office staff and distribute correspondence related to the review. Assess review data to determine areas of improvement for follow up physician training and communication.
• Maintain continuous accurate and complete documentation for department specific, ongoing, and situational audits and recommend revisions / improvements to audit functions
• Perform audits on-site, electronically or in the field.

Payment Integrity 20%

SIU / FWA - Detection and Prevention 30%

Related Responsibilities

MINIMUM REQUIREMENTS :

Bachelor's degree in Business, Healthcare Administration or related field with more than 3 years claims auditing experience; or more than 3 years experience in Fraud, Waste &

Abuse preferably in an HMO or MCO; or an equivalent combination of education and experience.

Experience in Medicare compliance

CPC and or CPC-H certification preferred

CPMA certification preferred

Understanding of Commercial insurance business practices and government health insurance products (Medicare& Medicaid).

Proficiency with healthcare coding (CPT / HCPCS, ICD-9 and ICD-10 & Revenue Codes)

Working knowledge and experience in cross-functional business segments and their integrated influences and relationships

Highly effective research, writing, and communication skills

Skilled with Microsoft Office Suite (Access, Word, Excel, PowerPoint)

Good problem solving skills

Excellent organizational skill

Strong attention to detail

Excellent critical thinking, and analysis skills

Ability to understand and interpret government health insurance laws and regulations

Ability to present an unpopular opinion

Ability to work well independently or with others

Ability to work well with both internal and external customers

WORKING CONDITIONS : Works in a standard office-based environment