Payment Integrity Auditor (35396)

Position Overview :

The Payment Integrity Auditor 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. The Auditor will provide education and guidance to associates on proper audit and claims accuracy methods. 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 :

• Support Payment Integrity and its audit functions
• Identify new audit areas by screen and analysis or audit samples
• Investigate potential over-utilization by performing reviews via prepayment claims review and post payment auditing
• Initiate and verify claims adjustments, maintain audit documentation and prepare statistical data
• Interact with providers to clarify clinical issues, documentation and billing practices
• Document and substantiate billing discrepancies to providers and resolve when appropriate
• Assist with development of audit tools, policies and procedures and provider educational materials.
• Analyze and trend provider performance data, and works with the Provider Engagement and Contracting Department to improve processes and compliance.
• 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 to obtain and maintain policy and general information regarding provider contracting, fee schedules, EDI edits, provider bulletins, and other information relevant to audit decisions
• Interpret data, analyze results and opportunities
• Develops reports and deliverables for management and communicates with all levels
• 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.

Core Company-Wide Competencies :

Job Specific Competencies :

FDR Oversight : N / A

Travel Expectations : N / A

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.