Performant Healthcare Audit Recovery Analyst "Data Mining" in United States
Healthcare Audit Recovery Analyst "Data Mining"
Location:United States - Remote
Status:Regular Full Time
The Healthcare Audit Recovery Analyst "Data Mining" is responsible for objectively and accurately complete claim audit reviews on assigned audits while meeting quality and productivity performance goals. This position makes determinations based on claims payment expertise and knowledge while using audit tools and resources available. Communicates and supports the identification of additional audit opportunities and participates in development of ideas as necessary.
Conducts claim audit reviews and determines if claims are appropriately paid in accordance with benefits, contracts and edits, includes review of specific coding and billing guidelines
Documents findings within audit tracking system and maintains thorough and objective documentation of findings
Investigates, researches, and analyzes claims data, applying knowledge of medical or pharmacy policy to determine details of fraudulent or abusive billing activity
Creates narrative rationale to correspond with audit determinations
As needed, supports findings during the appeals process
Serves as a claims payment resource; provides claims payment expertise, and claims payment guidance to the team
Works collaboratively with the audit team to identify vulnerabilities and/or cases subject to potential abuse
Monitors, tracks and reports on all work conducted
Consults with our clients, physicians, other claims payment resources and contractors as necessary
Maintains current knowledge of changes in technology, practice and regulatory issues that may affect our clients
Participates in process improvement activities and encourages ownership of and group participation in improvement initiatives
As needed, assists with quality assurance functions, development of medical review guidelines and training
Identifies and recommends opportunities for cost savings and improving outcomes
Attends conference calls and meetings as requested
Performs other duties as assigned
*Note - All employees and contractors for Performant Financial may and/or will have access to Sensitive, Proprietary, Confidential and/or Public data. As such, all employees and contractors will have ownership and responsibility to report any violations to the Confidentiality and Integrity of Sensitive, Proprietary, Confidential and/or Public data at all times. Violations to Performant’s policy related to the Confidentiality or Integrity of data may be subject to disciplinary actions up to and including termination.
Required Skills and Knowledge:
Working knowledge of coordination of benefits and medical claims processing
Knowledge of insurance programs, particularly the coverage and payment rules
Ability to be flexible and seizes the opportunity to cross train
Ability to maintain high quality work while meeting deadlines and performance metrics
Excellent organizational, interpersonal and communication skills
Strong problem solving skills
Excellent organizational, interpersonal and communication skills
Must be able to independently use standard office computer technology (e.g. email telephone, copier, etc.) and have experience using a case management system/tools to review and document findings
Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload, problem solve, work independently and with team members
Acute sense of professionalism and confidentiality
Typing skills and working knowledge of computer functions and applications such as MS office (Outlook, Word, Excel)
Intermediate level of proficiency with Microsoft Excel, Word and Access
Capability of working in a fast-pace environment, flexibility with assignments and the ability to adapt in a changing environment
Completion of Teleworker Agreement upon hire, and adherence to the Agreement (and related policies and procedures) including, but not limited to: able to navigate computer and phone systems as a user to work remote independently using on-line resources, must have high-speed internet connectivity, appropriate workspace able to be compliant with HIPAA, safety & ergonomics, confidentiality, and dedicated work focus without distractions during work hours.
Lift/carry/push/pull under and over 10lbs occasionally
Keying frequency, handling, reaching, fine manipulation
Education and Experience:
Bachelor’s degree or an equivalent level of competence obtained through experience, education and/or training.
Active unrestricted RN license in good standing
Certified Coder, a plus
7+ years healthcare claims processing
3+ years of experience in the health care industry, preferably in an auditing role
3+ years of experience with claims processing systems such as UNET, COSMOS, NDB, TOPS, AMYSIS, MHS, etc.
3+ years working with health care claims demonstrating expertise in, ICD-9/ICD-10 coding, HCPS/CPT-4 coding, and MS-DRG including medical billing experience for an Insurance Company or hospital Medical coding experience.
Other Requirements:•Must submit to and pass pre-hire background check, as well as additional checks throughout employment•Must be able to pass a criminal background check; must not have any felony convictions or specific misdemeanors, nor on state/federal debarment or exclusion lists.•Must submit to and pass drug screen pre-employment (and throughout employment).•Performant is a government contractor. Certain client assignments for this position requires submission to and successful outcome of additional background and/or clearances throughout employment with the Company. Visa sponsorship is not available.Job Profile is subject to change at any time.EEO Performant Financial Corporation is an Equal Opportunity Employer. Performant Financial Corporation is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, age, religion, gender, gender identity, sexual orientation, pregnancy, age, physical or mental disability, genetic characteristics, medical condition, marital status, citizenship status, military service status, political belief status, or any other consideration made unlawful by law. NO AGENCY SUBMISSIONS WITHOUT PERFORMANT AUTHORIZED AGENCY AGREEMENT AND APPROVED PERFORMANT JOB ORDER