Payment Integrity Analyst III - QA Analyst
$73,345–$113,247 year
RemoteUnited States
Job Summary
Lead the Policy and Payment Integrity team while accurately reviewing pre and post pay claim audits against client, policy, industry standards, and CMS guidelines. Verify and correct audit work from QC analysts and clinical appeal review teams, analyzing trends and interpreting documentation using clinical judgment. Oversee team quality and compliance, communicate deadlines, provide ongoing training, and assist in developing internal quality assurance measures and implementing best practices. Research healthcare policies and initiatives to support payment integrity efforts. This remote role supports CERIS's commitment to accuracy and transparency in healthcare payments through strategic project delivery and data-driven decision-making.
Required Qualifications
- Must maintain a current LPN, LVN and/or RN licensure (this applies only to RN hires, not coders)
- Previous experience in one or more of the following areas required: Medical bill auditing
- Experience in the acute clinical areas of facilities in O.R., I.C.U., C.C.U., E.R., Telemetry, Medical/Surgical, OB or L&D, Geriatrics and Orthopedics
- Knowledge of worker's compensation claims process
- Prospective, concurrent and retrospective utilization review
- 3+ years healthcare revenue cycle or payment integrity experience
- 3+ years of relevant experience or equivalent combination of education and work experience
Desired Qualifications
- Preferred experience with health insurance denials and/or appeals, payer audits, or vendor audits
- Bachelor's degree in healthcare or related field preferred
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