Payment Integrity Lead

Position Summary:

The Payment Integrity Lead is responsible for assisting with the planning, coordinating, and managing assigned projects, area(s) to ensure an efficient and cost-effective outcome of all task and goals. The Lead is responsible for assisting the manager with daily operations related to audit and recovery. The Lead will handle all responsibility in accordance with established corporate and departmental policies and procedures.

General Duties/Responsibilities (May include but are not limited to):

• Assists the Manager with prioritizing tasks and assigning work to employees and initiate corrective measures to resolve problems.

·         Serves as the subject matter expert as they relate to overpayment recoveries and claims audits.

• Lead and promote the professional development of the team through selection, development, and exploration of more effective methods of managing projects and timelines.
• Validates vendor invoices for accuracy and submits timely
• Assist the manager with the recommendation in acquisition of technology and other tools or equipment and resources to optimize departmental performance and output.
• Interface with diverse levels of internal and external personnel to develop and maintain effective rapport and to resolve issues and inquiries.
• Responds to provider inquiries, either telephonically or in writing, regarding overpayment refund requests.
• Collaborates with internal team in ensuring claims payment errors which results in overpayments are recovered timely
• Collaborates with other departments in resolving potential configuration issues and updates on eligibility and other insurance information

·         Assist with implementation and management of contracted payment integrity vendors.

·         Works with recovery vendors in ensuring identified overpayments are accurate based on internal guidelines and regulatory requirements.

• Assists with the reviews of overpaid claims and determines if root cause is due to system configuration, training issues or erroneous claims processing. 
• Communicates root causes and issues that impact claims processing quality to Management on a weekly/monthly basis and makes recommendations for improvement.

·         Supports department initiatives in improving processes and workflow efficiencies.

·         Assists the manager with the reviews of claims for statistical and payment accuracy. Ensure appropriate payments or denials and use of adjustment or reason codes are correct.

• Identifies data trends and reports findings to department management with suggestion for resolution and opportunities for process improvement.

·         Administer and adhere to Corporate and departmental policies, practices, and procedures.

• Performs other related duties as assigned.

SUPERVISORY RESPONSIBILITIES:

N/A

Minimum Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

·         Minimum Experience:

o   3-5 years collectively of claims, audit, recovery, and customer service experience

o   1-2 years in a lead role or equivalent experience.

o   2+ years’ experience in claims overpayment recovery, preferably in Medicare Advantage setting.

o   1-2 years medical claims auditing experience is a plus.

·         Education/Licensure:

o   High School Diploma or general education degree (GED), required. Some college preferred.

·         Other:

o   Strong organizational, planning, analytical and communication skills.

o   Excellent interpersonal skills necessary to interact with all levels of employees internally and externally.

o   Working knowledge of PC application, Word, Excel, and/EZCAP preferred.

o   Working knowledge of different claims coding requirements, payment methodology (i.e., APC, Medicare fee schedules, etc.), coordination of benefits

o   Knowledge of medical terminology, standard coding and reference publications, CPT, HCPC, ICD-9, ICD-10, DRG, etc.

• Work Environment:

o   The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

·         While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

• The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

·         The employee will be required to travel to other clinic locations away from his/her home locations; patient homes; corporate offices and/or clinics in other territories not near home location.