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Payment Integrity Specialist
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. These activities may be perpetrated by health care providers, facilities, members, brokers and/or employer groups. This individual must be able to effectively present information and establish clear understanding and buy-in.
- 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%
- Research, interpret and provide clear direction to the stakeholder departments on new and changing code requirements, covered and non-covered determinations and payment schedules and provide fact-based recommendations.
- Provide leadership and collaborate on internal and external audits.
- Develop financial models and tools, including cost-benefit analysis, claims trend analysis.
SIU / FWA - Detection and Prevention 30%
- Develop and perform a comprehensive FWA monitoring program for government programs (Medicare and Medicaid)
- Investigates cases of known, reported or suspected fraud, waste and abuse
- Gather, analyze, evaluate facts and evidence and draw sound conclusions
- Determine whether fraud (intent) or abuse (without defined intent) was the outcome utilizing sound conclusions
- Assist with identifying opportunities for improvement and correction actions designed to strengthen internal controls, correct underlying problems that may result in fraud, waste or abuse and prevent further misconduct
- Assist with oversight of auditing services from outside vendors and HNE business partners.
- Manage and investigate incidents/leads as assigned related to areas of regulatory, compliance, fraud, waste and abuse and violation of policy and procedure. Report issues to Compliance Manager and Director of Payment Integrity/SIU
- Develop reporting for FWA and compliance activities
- Stays abreast of current coding issues and changes, reviews medical coding trends and identifies potential training needs.
- Ensure compliance with regulatory requirements and standards. Understand regulatory environment and ensure contractual compliance with federal and state requirements (Medicare, Medicaid).
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 Medicaid/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 skills
- 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
Time: Full time
Updated: 5/1/2023 7:51:35 AM