Payment Integrity Analyst III - Trainer
$73,345–$113,247 year
RemoteUnited States
Job Summary
Lead the Policy and Payment Integrity (PPI) team while accurately reviewing pre and post pay claim audits based on client, policy, industry standards, and CMS guidelines. Oversee team member work for quality and compliance, communicate deadlines and productivity goals, and provide ongoing training to ensure policies are followed. Verify and correct audit work completed by PPI QC analysts and clinical appeal review teams as needed. Review, analyze, and complete internal audits and appeals in accordance with client policy and CMS guidelines, utilizing clinical judgment to interpret documentation for itemized bill, DRG, and specialty audits. Assist with developing internal quality assurance measures, researching best practices, and attending clinical team and company meetings. This remote position requires current LPN, LVN, or RN licensure and 3+ years of healthcare revenue cycle or payment integrity experience.
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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