Job Details

Job Summary

Responsible for planning, developing, and directing the implementation of techniques to ensure the maintenance of performance and quality levels in the Business' products and processes. Reviews operation process designs and establishes procedures and techniques for operational standards. Confers with customers to define and resolve Knowledge/Skills/Abilities.

With direction from Director or AVP of Payment Integrity, leads the implementation of department/companywide initiatives that would include one or all of the following areas: Overpayment Recovery, Pre- and Post-pay COB, Subrogation, Premium Enhancement (such as ESRD and Medicare Secondary Payer) and Pre-pay Editing for correct coding and medical payment policies. Many of these activities include oversight of vendors that are supplemental to internal processes and activities.

Manage team members and responsible for executing projects and activities involving inventory management, information reporting, database configuration, procedures, and workflow to ensure quality controls and timely turnaround. Responsible for facilitating meetings with health plans and vendors for ideation and approval of payment integrity initiatives.

Analyze and document business rules requirements to corporate configuration for COB and claims edits logic in the QNXT systems as well as maintenance to the internal Payment Integrity Tracking databases. Assist and execute tasks and projects in ensuring CMS and state regulatory requirements are met, for Pre-pay Edits, Overpayment Recovery, COB and Subrogation, which improves encounter submissions, reduces G&A costs, and continues to drive positive operation and financial outcomes for all solutions.

Evaluates analytical findings to ensure accurate interpretation of meaningful data mining results. Designs programs that prioritize identified and resolve payment issues.

Job Qualifications

Required Education: Bachelor's degree or equivalent combination of education and experience

Required Experience: 5-7 years

Preferred Experience: 10+ years