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Payment Integrity Analyst-PCHP

Date:  Jun 9, 2022
Location: 

Dallas, TX, US

Category:  Corporate and Professional Jobs
Job Type:  Day
Requisition ID:  680781

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion.

 

Primary Purpose

Parkland Community Health Plans (PCHP’s) Payment Integrity Analyst will be responsible for timely and accurate review and approval/denial of claim overpayments identified by PCHP’s payment integrity vendors. The payment Integrity Analyst will also collaborate with various PCHP departments and vendors to resolve questions and issues that arise during overpayment identification and recovery processes to ensure timely and accurate recovery of overpayments and to assist in overpayment prevention.

 

Minimum Specifications

 

Education

  • High School diploma or equivalent is required.
  • Bachelor’s degree in business administration, accounting, finance, healthcare, or a related field is preferred.

 

Experience

  • Three years of experience in payment integrity, claims processing, and/or claims auditing in a health care organization.
  • Experience with interpreting complex contractual terms with Providers, Facilities, Plan Partners, and/or Delegated Groups.
  • Experience working with hospital and provider billing departments.
  • Experience with QNXT or FACETS claims system and NetworX Pricer is preferred.
  • Experience in a Health Plan or Managed Care Organization (MCO) is preferred.
  • Experience with Medicaid Claims for the State of Texas is preferred.

 

Equivalent Education and/or Experience Certification/Registration/Licensure Required Tests for Placement Skills or Special Abilities

  • Strong understanding of healthcare claims data, pricing, and claims editing concepts, including UB04 and HCFA 1500 claim content.
  • Strong working knowledge of health insurance concepts, practices and procedures including understanding of provider payment methodologies and claims processing workflows, from receipt through final adjudication.
  • Knowledge of payment integrity services including data mining, clinical auditing, coordination of benefits, or fraud, waste, and abuse.
  • Strong analytical and research abilities to triage issues and perform reconciliations or data analysis.
  • Working knowledge of Federal and State regulatory rules regarding claims adjudication.
  • Ability to identify root cause for issues and incorporate findings into process improvement initiatives.
  • Proficiency with Microsoft Office Excel, Word, and Outlook.
  • Excellent verbal and written communication skills to interact with internal and external stakeholders.
  • Strong organizational skills and the ability to manage multiple competing projects and deadlines.
  • Demonstrated ability to collaborate effectively and work as part of a team in a fast-changing environment.
  • Strong knowledge of Texas State Medicaid Guides & Handbooks
  • TMHP Provider Manuals, Uniform Managed Care Contract (UMCC), Uniform Managed Care Manual (UMCM), etc. is preferred. Responsibilities
  • Performs timely and accurate analysis, review and approval or denial of claim overpayments identified by PCHP’s payment integrity vendors to drive incremental savings for the organization.
  • Researches reimbursement regulations for claim payment compliance reviews and documentation to support current audit findings.
  • Resolves questions and issues that arise during overpayment identification and resolution processes.
  • Communicates, collaborates, and cooperates with various teams (external and internal) in a respectful and responsible manner to ensure timely and accurate identification and recovery of overpayments.
  • Identifies, analyzes, and tracks trends related to identified overpayments and recoveries.
  • Performs root cause analysis to identify the source and underlying cause of claims overpayments.
  • Partners with the Claims Teams to identify and implement overpayment prevention and cost avoidance strategies.
  • Partners with PCHP’s Analytics Team to implement internal analytics for overpayment identification.
  • Serves as PCHP’s subject matter expert for overpayments and recoveries.
  • Assists PCHP’s Claims Resolution Analysts with claim projects as needed.
  • Adheres to all compliance requirements and complies with HIPAA regulations.
  • Performs other duties as assigned.

 

Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.


Nearest Major Market: Dallas
Nearest Secondary Market: Fort Worth

Job Segment: Patient Care, Public Health, Business Process, Healthcare Administration, Medicaid, Healthcare, Management