Cleveland Clinic Health System seeks a Lead Provider Payment Integrity Analyst to conduct complex, in-depth analysis of claim payments and methodology to identify cost avoidance and overpayment recovery opportunities. In this role, you will apply root cause analysis to design solutions and coordinate implementation with stakeholders, vendors, and providers, ensuring compliance with all guidelines, contracts, and policies.
What You'll Do
- Conduct thorough analysis of all medical claims for adherence to state/federal guidelines, provider contracts, BCBSRI policy, national coding guidelines, and industry standards.
- Create new recurring and ad-hoc reports to identify cost avoidance and overpayment opportunities using large data sets on multiple variables.
- Provide data, analysis, and recommendations to management on findings affecting payments, including policy, contract issues, provider errors, pricing, systems, and claim processes.
- Work with internal stakeholders to make necessary technical updates to systems, policies, and procedures and coordinate provider education.
- Track and report progress of prospective and retrospective cost avoidance and overpayment recoveries.
- Carry out new recovery concepts within established deadlines with high accuracy.
- Resolve challenges to proposed cost avoidance and overpayment concepts throughout the organization.
- Build strong stakeholder relationships and deliver solutions that meet expectations.
- Develop written reports in accordance with reporting standards.
- Ensure all audit findings, exceptions, and proposed adjustments are well defined and explained in reports.
What We're Looking For
- Bachelor’s degree in Business, Healthcare, Finance, Mathematics, Statistics or related field; or equivalent combination of education and experience.
- Seven or more years of experience in medical claims review or claims processing.
- Seven or more years of experience in quantitative or statistical analysis, preferably in health care.
- Experience using PC SAS (Enterprise Guide SAS preferred), Crystal, SQL, and/or Business Objects.
- Proven analytic expertise using Microsoft Excel and Access, database query capabilities, and ability to evaluate data at all levels of detail.
- Experience with manipulating large datasets.
- Experience with medical terminology, claim audit procedures, provider contracts, claims processing procedures and guidelines.
- Knowledge of medical claims data and Correct Coding Initiative (CCI) guidelines.
- Audit skills and the ability to interpret and apply Federal and State regulations, coding and billing requirements.
- Demonstrated ability to review analytical, data and audit findings to identify coding trends and risk areas.
- Ability to interpret contract reimbursement schedules and policies.
- Strong organizing skills, with ability to prioritize and respond to shifting deadlines.
- Ability to manage diverse and deadline-oriented workflow.
- Strong analytical, conceptual, and problem-solving skills to evaluate complex business requirements.
Nice to Have
- Knowledge of diagnostic related groups (DRG’s) and American Hospital Association Official Coding Guidelines.
- Knowledge of Current Procedural Terminology (AAPC Certification preferred).
- Familiarity and ability to interpret hospital/provider contracts and medical claims reimbursement.
- Financial/Accounting methodology exposure.
- Experience with lean or six sigma.
Technical Stack
- PC SAS (Enterprise Guide SAS preferred)
- Crystal
- SQL
- Business Objects
- Microsoft Excel
- Microsoft Access
Benefits & Compensation
- Compensation range: $92,700.00 - $139,100.00
- Flexible work arrangements including remote and hybrid opportunities.
- Paid time off.
- Tuition reimbursement and assistance with student-loan repayment.
- Health, dental, and vision insurance.
- Programs that support mental health and well-being.
- Competitive pay, bonuses, and investment plans.
- Commitment to growing and developing employees.
- Additional paid time to volunteer.
Work Mode
This position is hybrid and based in Providence, RI.
BCBSRI is an equal opportunity employer.
