Payment Integrity Analyst - Remote - Emblem Health

• Validate claims files from third party vendors to determine if overpayment was made based on criteria developed by the
department.
• Review files from third party vendors and provide responses when claim overpayments are inaccurately identified by the
vendor.
• Review rate sheets that claims adjudicate against to ensure that rate sheet is correct based on providers' contracts.

Principal Accountabilities

• Review and finalize claims cases assigned to payment integrity queues.
• Provide validation and review of claims overpayments identified by third party vendors for recovery.
• Provide review and validation of overpayment trends (consistent overpayments) presented by third party vendors
for possible recovery efforts.
• Participate in regular work groups with FRU, Vendor contracts, PNM, and claims Operations to help attain greater
efficiency and effectiveness for the Enterprise. 20%
• Provide Claims, Operations, PNM, and Medical Economics with overpayment information from third party vendors
to uncover underlying reasons for claim payment errors and assist with improving claim payment accuracy and
reducing overall medical spend.

Education, Training, Licenses, Certifications

• Bachelor's Degree, preferably in business administration or related.

Relevant Work Experience, Knowledge, Skills, and Abilities

• 3 - 5+ years of relevant, professional work experience. (R)
• 1 - 2+ years' experience analyzing operational processes and provider billing/claims data. (R)
• Additional years of experience/specialized training may be considered in lieu of educational requirements.
• Prior knowledge in insurance coding and/or claims experience. (R)
• Strong knowledge of contracts, procedures and systems. (P)
• Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audience. (R)
• Proficiency in MS Office (Word, Excel, PowerPoint, Access, Outlook, Teams, etc.). (R)
• Ability to conduct research, analyze data; to categorize and report findings; and to identify patterns/trends in the data. (R)
• Strong attention to detail; analytical and problem-solving skills. (R)
• Ability to identify issues and to develop recommendations to improve processers and procedures. (P)
• Ability to successfully organize, prioritize and manage multiple tasks with conflicting priority levels and deadlines. (R)

Additional Information

• Requisition ID: 1000000632
• Hiring Range: $65,000-$75,000