Payment Integrity Analyst at WPS Health Solutions in Newark, New Jersey
Posted in Other 30+ days ago.
Job Description:
Description
Role Summary:
Be proficient on all processes surrounding adjudication of claims and member eligibility. Responsibilities include maximizing capabilities of claims editing tools and determiningpre-payment and post-payment solutions that identify and recover inappropriate claim payments and overpayments. Provide actionable intelligence for systematic improvements to improveaccuracy, lower costs, and improve provider satisfaction. Conduct investigations of potential healthcare fraud, abuse, or waste.
In this role you will:
Analytics/Decision Making (70 %)
- Analyze and resolve complex issues on claims identified by our payment integrity algorithm, which includes eligibility of the patient, delving into patient's medical history, validation of medical coding, and interpretation of plan/policy provisions and pricing arrangements.
- Conduct in-depth research and analytics of claims data to identify trends and emerging issues on provider billing errors and fraudulent submitted claims and prepare detailed reports with recommendations of best practices.
- Achieve key performance metrics and cost containment goals.
- Assist with development and implementation of action plans for procedure and workflow improvement.
- Track processing inefficiencies to analyze trending for specific claim types, providers, processors, plans, and processing error types to provide more meaningful insight into recurrent problem areas and provide recommendations for corrective action.
- Access resource information through various on-line systems that will assist in claims resolution (e.g. Refund File, CES, Case Management, and EncoderPro).
- Act as a resource and liaison to business partner on interpretation of certificate language, provider contracts, regulations, policies, and procedures.
- Perform data analytics on claims data to assess for any potential healthcare fraud, abuse, or waste.
- Investigate any tips or information received through our fraud tip line/mailbox. Prepare case findings and recommendations and forward to management and/or WPS Legal Team.
Leadership (30 %)
- Communicate root cause and recommendations to Senior Management and direct and implement solutions.
- Track and report cost containment inventories for inventory management.
- Mentor and train new and/or existing team members on procedures, workflow, analysis and trending, reports, and other related information.
- Communicate with internal and external customers to determine claim processing and correspondence accuracy.
- Participate in quality teams such as Coding Governance Committee to create or enhance editing logic, workflows, and guidelines to ensure accuracy and process improvement.
This role could be a good fit if you:
- Like to dig deeper and investigate
- Possess strong attention-to-detail and communication skillsets
- Enjoy an interesting variety of situations
You'll benefit from this experience by:
- Being an integral part of a collaborative, supportive team
- Enjoying a remote work from home opportunity
- Seeing firsthand the cost-savings impact from your work
- Deepening your medical coding and leadership experience
You need to have:
- Bachelor's degree in Business or related field OR equivalent post high school education and/or work related experience
- 1 year or more of related work experience
- Certified Professional Coder or ability to obtain within 1 year of hire
We also prefer:
- 4 or more years of experience in medical claim coding
- 1 or more years of Auditing experience
- Experience investigating healthcare fraud
- Experience writing reimbursement policies
- Understanding and familiarity of claim coding requirements
Compensation and Benefits
- Eligible for annual Performance Bonus Program
- 401(k) with dollar-per-dollar match up to 6% of salary
- Competitive paid time off
- Health and dental insurance start DAY 1
- Vision insurance
- Flexible spending, dependent care, and health savings accounts
- Short- and long-term disability, group life insurance
- Dress for your day
- Innovative professional and cognitive development programs
Who We Are
WPS Health Solutions is an innovator in health insurance and a worldwide leader in claims administration, serving millions of beneficiaries in the United States and abroad.
Founded in 1946, WPS offers health insurance plans for individuals, families, and seniors, and group plans for small and large businesses. We are a world-class claims processor and program administrator for the government's Medicare program. And we manage benefits for millions of active-duty and retired military personnel and their families.
Our Purpose and Values
Our purpose is to make healthcare easier for those we serve. Click Here
Our values - Customer Focused, Individual Responsibility, Mutual Respect, and Driven & Passionate - are the core of who we are and how we conduct business every day.
WPS Health Insurance
WPS Health Insurance offers high-quality health insurance plans for individuals and families, Medicare supplement plans for seniors, and group health plans for businesses of every size.
http://wpshealthsolutions.com/business-units/wpshi.shtml
Military and Veterans Health
WPS Military and Veterans Health administers claims and provides customer service and related activities for the U.S. Department of Defense and the U.S. Department of Veterans Affairs and their beneficiaries.
http://wpshealthsolutions.com/business-units/wpsmvh.shtml
Government Health Administrators
WPS Government Health Administrators manages Medicare Part A and Part B benefits for more than 7 million beneficiaries. As one of the largest contractors for the Centers for Medicare & Medicare Services, we've served Medicare beneficiaries and their health care providers since 1966.
http://wpshealthsolutions.com/business-units/wpsgha.shtml
WPS Health Plan
WPS Health Plan offers Health Maintenance Organization and Point-of-Service plans to the group and individual markets in eastern and north-central Wisconsin, plus third-party administrator services.
http://wpshealthsolutions.com/business-units/wpshi.shtml
EPIC Specialty Benefits
EPIC Specialty Benefits provides businesses group insurance products that cover:
- Life
- Disability
- Dental
- Vision
- Voluntary benefits
http://wpshealthsolutions.com/business-units/epicsb.shtml
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Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)
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