Payment Integrity Analyst III - Trainer

CorVel Corporation; Fort Worth (TX); Hybrid; USD 70,000 - 100,000; Full time

Job summary

CorVel Corporation is seeking a Payment Integrity Analyst (Team Lead) to guide the Policy and Payment Integrity (PPI) team while delivering core audit responsibilities. You will review pre- and post-pay claims using client policies, CMS guidelines, and industry standards, with emphasis on itemized bill review, DRG validations, and appeals.

The role requires strong analytical abilities, clinical judgement, and proficiency in healthcare revenue cycle processes, with the ability to lead a remote

Qualifications

• Must maintain a current LPN, LVN and/or RN licensure (RN hires only).
• Preferred experience with health insurance denials or appeals, payer audits, or vendor audits.
• Experience in medical bill auditing and acute clinical care areas (OR, ICU, CCU, ER, etc.).
• Knowledge of worker’s compensation claims process and utilization review.

Responsibilities

• Assist with staff communication, updates, issue resolution, and goal setting.
• Oversee team quality, provide training to ensure policy compliance.
• Verify and correct audit work by PPI QC analysts and appeals teams.
• Review and complete internal audits and appeals per CMS guidelines and policy.
• Use clinical judgement to review documentation for claim audits.
• Interpret and apply client policies and CMS guidelines in CERIS reviews.
• Utilize tools to complete audits and appeals in a timely manner.
• Attend meetings and participate in ongoing education and trainings.
• Perform additional duties as assigned.

Skills

CMS knowledge

ICD-10/DRG

Revenue cycle

Microsoft Excel

Pivot Tables

Database management

Project management

Communication

Analytical skills

Attention to detail

Education

RN/LPN/LVN licensure

Bachelor’s degree in healthcare or related field

3+ years healthcare revenue cycle experience

3+ years relevant experience or equivalent combination

Tools

Microsoft Excel

Pivot Tables

Database Management

Job description

TX - Fort Worth
5128 Apache Plume Rd
Suite 400
Fort Worth, TX 76109, USA

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

This is a remote position.

ESSENTIAL FUNCTIONS & 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 (this applies only to RN hires, not coders)
• 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 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.

In general, our opportunities will be posted for up to 1 year from date of posting, or until we have selected candidate(s) to fulfill the opening, whichever comes first.

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.

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.
For further information, please review the Know Your Rights notice from the Department of Labor.