Payment Integrity Analyst III

CorVel; Fort Worth (TX); Remote; USD 70,000 - 109,000; Full time

Job summary

An established industry player is seeking a Payment Integrity Analyst (Team Lead) to oversee the Policy and Payment Integrity team. In this remote role, you will lead audits and reviews to ensure compliance with client policies and industry standards. Your expertise in claims processing and healthcare revenue cycles will be crucial as you guide a team in delivering high-quality results. This position offers an exciting opportunity to contribute to best practices in payment policy while enjoying a supportive work culture that values accountability and teamwork. If you're passionate about improving healthcare payments and leading a dedicated team, this role is perfect for you.

Benefits

Medical Insurance

Dental Insurance

Vision Insurance

401K

Paid Time Off

Flexible Spending Account

Health Savings Account

Long Term Disability

Life Insurance

Accident Insurance

Qualifications

• 3+ years in healthcare revenue cycle or payment integrity required.
• Must maintain a current LPN, LVN, and/or RN licensure.

Responsibilities

• Lead team communication and ensure compliance with policies.
• Conduct quality assurance reviews and audits based on guidelines.

Skills

Claims Processing

ICD-10 Coding

Healthcare Revenue Cycle

Analytical Skills

Communication Skills

Problem-Solving Skills

Attention to Detail

Education

Bachelor's Degree in Healthcare or Related Field

LPN, LVN, and/or RN Licensure

Tools

Microsoft Office

Database Management

Job description

JOB SUMMARY:

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. They will assist with the development of internal quality assurance measures based on client policy and industry guidelines, perform quality assurance reviews, and assist in researching and implementing best practices related to payment policy and/or policy initiatives.

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:

• Ability to demonstrate understanding of CMS and commercial payer policy in written and verbal format.
• Strong understanding of claims processing, ICD-10 Coding, DRG Validation, Coordination of Benefits.
• Strong understanding of healthcare revenue cycle and claims reimbursement.
• Proficient in Microsoft Office including Pivot Tables and Database Management.
• Demonstrate ability to manage multiple projects, set priorities, and adhere to committed schedule.
• Strong interpersonal skills and adaptive communication style, complex problem-solving skills, drive for results, innovative.
• Excellent written and verbal communication skills.
• Proven track record of delivering concrete results in strategic projects/programs.
• Strong analytical and modeling ability and distilling data into actionable results.
• Superb attention to detail and ability to deliver results in a fast-paced and dynamic environment.

EDUCATION/EXPERIENCE:

• Must maintain a current LPN, LVN, and/or RN licensure.
• Preferred experience with health insurance denials and/or appeals, payer audits, or vendor audits.
• Previous experience in one or more of the following areas required:
• Medical bill auditing.
• Experience in the acute clinical areas of facilities in O.R., I.C.U., C.C.U., E.R., Telemetry, Medical/Surgical, OB or L&D, Geriatrics, and Orthopedics.
• Knowledge of worker's compensation claims process.
• Prospective, concurrent, and retrospective utilization review.
• Bachelor’s degree in healthcare or related field preferred.
• 3+ years healthcare revenue cycle or payment integrity experience.
• 3+ years of relevant experience or equivalent combination of education and work 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 the 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.

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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