Job Description
This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description A Payment Integrity Data Mining Consultant I is a professional who is market/client facing and responsible for identifying new audit opportunities, researching new pricing methodologies, and engaging with various work teams to generate systems automation and enhancement capabilities in our state-of-the-art audit workstation. • Identify, develop, and implement new concepts that recognize incorrect payments based on industry experience and regulatory research. • Analyze client data and generate high-quality recoverable claims. • Assist in the identification, validation, and documentation of moderate to more complex recovery projects. Qualifications • High School Diploma or equivalent required; BA/BS in Business Administration or related field preferred but not necessary. • 4-5+ years of knowledge of direct claim processing/reimbursement, medical facility contracts, fee schedules, inpatient/outpatient/physician claims required. Requirements • Prior claims auditing or consulting experience desirable in either a provider or payer environment. • Excellent communication skills both oral and written. • Strong interpersonal skills that support collaborative teamwork. • Microsoft Office Proficient: Word and Excel; Access – highly preferred. • Provide recommendations for improving payment integrity processes, fraud prevention measures, and operational efficiency based on audit findings. • Collaborate & establish strong relationships with internal and external stakeholders to define, align, and deliver payment accuracy initiatives. • Work with audit teams to ensure the concepts being deployed are working as expected with higher findings, thus ensuring higher hit rates on the concepts deployed. Preferred Skills • Knowledge of payment systems, financial transactions, and claims processes end to end. • Understanding of payment integrity concepts and fraud detection methodologies. • Experience in auditing, payment processing, or financial fraud prevention is a plus. • Experience working within a health plan, managed care organization, provider operated healthcare environment, or third-party administrator. • Development of end-to-end payment integrity reports like Data Intake, Audit Selections, Findings, Appeals, Medical Record Management, Audit Operations, Recovery Operations, Provider Correspondence, and Forecasting & Invoicing. Roles & Responsibilities • Utilize healthcare experience to perform audit recovery procedures. • Identify overpaid claims. • Identify and define issues, develop criteria, review, and analyze contracts and Health Plan reimbursement policies and various state and federal regulations. • Enter and document the incorrect payment issue into Devlin’s systems accurately and in accordance with standard procedures. • Update and develop new and current audit recovery report ideas and work with the IT team to automate the process. • Research reimbursement regulations for claim payment compliance reviews and documentation to support current audit findings. Location Work@Home USA, United States of America Apply tot his job