Payment Integrity Analyst

MetroPlus; New York (NY); On-site; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking a Payment Integrity Analyst to enhance healthcare financial processes. In this dynamic role, you will develop strategies to recover and prevent unnecessary medical expenses while optimizing claims accuracy. Your analytical skills will be crucial in identifying savings opportunities and implementing effective mitigation strategies. Join a mission-driven organization that values collaboration and innovation, and make a significant impact on the healthcare landscape while working alongside a dedicated team committed to improving the lives of New Yorkers. This is a fantastic opportunity to grow in a supportive environment focused on excellence and integrity.

Qualifications

• 5+ years of experience in claims within healthcare or insurance.
• Extensive knowledge of audit methods and payment processes.

Responsibilities

• Develop a strategic roadmap to recover unnecessary medical expenses.
• Optimize claim editing, auditing, and recovery programs.

Skills

Data Analysis

Problem-Solving

Communication Skills

Quantitative Research

Process Improvement

Education

Bachelor's Degree

Tools

Excel

Data Systems

Job description

Empower. Unite. Care.

MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

About NYC Health + Hospitals

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

The Payment Integrity (PI) Analyst will assist in the development of a strategic roadmap to recover, eliminate, and prevent unnecessary medical-expense spending and support the execution for a comprehensive claim accuracy program. The incumbent will optimize pre/post claim editing, auditing, and claim recovery programs that will drive incremental value year over year. The PI Analyst will employ use of analytics, trends, competitor benchmarking, and outcomes to continually identify savings opportunities, develop mitigation strategies to avoid future overpayments/underpayments, and implement plans to achieve business goals.

Job Description

• Assist in the development of a stellar payment integrity unit capable of proactively identifying and investigating payment issues and working with stakeholders to develop mitigation strategies to prevent future occurrences, with the ability to review impacts holistically.
• Assist in the development of a comprehensive, strategic roadmap to recover, eliminate, and prevent unnecessary medical-expense spending by reviewing upstream and downstream processes.
• Identify overpayment/underpayment opportunities by data mining, investigation, and quality review on benefit and/or provider configuration, rate loads, rate assignments, COB, claims payment logic, etc.
• Support the execution and maintenance of a corporate claim accuracy program by optimizing pre/post claim editing, auditing, and claim recovery programs.
• Assist in the development and deployment of mitigation strategies to avoid future overpayments, driving incremental value year over year in both medical and administrative cost savings.
• Manage the day-to-day financial recovery vendor relationships, validating that identified overpayments are valid and recouped.
• Assist in the development and implementation of dashboards to monitor performance.
• Complete and analyze trending reports to identify favorable/unfavorable trends.
• Analyze departmental performance trends and assist with identifying new opportunities to streamline processes and improve performance of key metrics.
• Assist in developing and maintaining payment integrity policies and procedures.

Minimum Qualifications

• Bachelor’s degree required
• A minimum of 5 years’ working experience within claims in the healthcare or insurance industry
• Extensive knowledge of health care provider audit methods and provider payment methods, clinical aspects of patient care, medical terminology, and medical record/billing documentation
• Proven ability to apply quantitative and/or qualitative research and data analysis techniques to improve operational processes.
• Must understand trend information and be familiar with claim coding practices and industry issues in Medicare payment methodologies.
• Advanced level experience with Excel and other data systems

Professional Competencies

• Strong problem-solving skills
• Excellent communication skills, both written and verbal
• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Proven track record in building and fostering relationships at all levels of the organization
• Work well in a fast-paced environment, both independently and partnering with other business areas to achieve objectives.
• Curious mindset with a focus on process improvement