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Job Description
- Research and Analysis
- Serve as contact for external vendors and internal departments to support operations and payment integrity activities.
- Research and respond to low to high priority complex internal and external inquiries.
- Analyze and coordinate vendor performance reviews using KPIs (e.g., recovery yield, turnaround time, false positive rates, provider abrasion).
- Coordinate reconciliation of vendor invoices, validating against contractual terms, recoveries, and performance metrics.
- Is proficient at utilizing a variety of resources including but not limited to on-line information files and databases, Medicare/other plan guidelines, plan certificates, provider contracts.
- Update and create CES and Cotiviti pend resolutions.
- Business Analysis & Reporting
- Analyze operational and financial data to identify trends, savings opportunities, and anomalies.
- Assess business impact of new edits and changes in medical reimbursement policies/guidelines.
- Initiate, develop, coordinate and implement cost/benefit analysis of claims processing.
- Develop documentation, including cost/benefit and business impact analysis and recommendations to implement and/or improve claims processing.
- Collaborate with IT and data teams to validate extracts, reconciliations, and vendor reporting feeds.
- Operational & Strategic Alignment
- Recommend process improvements to increase efficiency and results.
- Identification and resolution of issues and trends as a result of researching and responding to implementation requests, problem reports, and inquiries.
- Support cross-functional projects, including audit response, regulatory requests, and enterprise cost-containment strategies.
- Act as SME (subject matter expert) on payment integrity activities, workflow design, and best practices.
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
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