Payment Integrity Analyst

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

The Payment Integrity (PI) Analyst will assist in the development of a strategic roadmap to recover, eliminate, and prevent unnecessary medical-expense spending and support the execution for a comprehensive claim accuracy program. The incumbent will optimize pre/post claim editing, auditing, and claim recovery programs that will drive incremental value year over year.  The PI Analyst will employ use of analytics, trends, competitor benchmarking, and outcomes to continually identify savings opportunities, develop mitigation strategies to avoid future overpayments/underpayments, and implement plans to achieve business goals.

• Assist in the development a stellar payment integrity unit capable of proactively identifying and investigating payment issues and working with stakeholders to develop mitigation strategies to prevent future occurrences, with the ability to review impacts holistically.
• Assist in the development of a comprehensive, strategic roadmap to recover, eliminate, and prevent unnecessary medical-expense spending by reviewing upstream and downstream processes.
• Identify overpayment/underpayment opportunities by data mining, investigation, and quality review on benefit and/or provider configuration, rate loads, rate assignments, COB, claims payment logic, etc.
• Support the execution and maintenance of a corporate claim accuracy program by optimizing pre/post claim editing, auditing, and claim recovery programs.
• Assist in the development and deployment of mitigation strategies to avoid future overpayments, driving incremental value year over year in both medical and administrative cost savings.   
• Manage the day-to-day financial recovery vendor relationships, validating that identified overpayments are valid and recouped.
• Assist in the development and implementation of dashboards to monitor performance.
• Complete and analyze trending reports to identify favorable/unfavorable trends.
• Analyze departmental performance trends and assist with identifying new opportunities to streamline processes and improve performance of key metrics.
• Assist in developing and maintaining payment integrity policies and procedures.

• Bachelor’s degree required 
• A minimum of 5 years’ working experience within claims in the healthcare or insurance industry
• Extensive knowledge of health care provider audit methods and provider payment methods, clinical aspects of patient care, medical terminology, and medical record/billing documentation
• Proven ability to apply quantitative and/or qualitative research and data analysis techniques to improve operational processes.
• Must understand trend information and be familiar with claim coding practices and industry issues in Medicare payment methodologies. 
• Advance level experience with Excel and other data systems

Professional Competencies

• Strong problem-solving skills
• Excellent communication skills, both written and verbal
• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Proven track record in building and fostering relationships at all levels of the organization
• Work well in a fast-paced environment, both independently and partnering with other business areas to achieve objectives. 
• Curious mindset with a focus on process improvement

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