Health Insurance Payment Analyst III
The Health Insurance Payment Analyst III performs cross functional activities for defined task areas related to the Payment Error Rate Measurement (PERM) program developed by the Centers for Medicare and Medicaid Services (CMS). Typical duties for this position include tasks related to the completion of detailed and precise audits, second-level reviews of claims processing systems, and the creation / analysis of reports. This position may function in a lead capacity for the review of remote states. This position also requires travel in the local Maryland, Virginia, and District of Columbia area to review and determine if monies paid by the states were made in accordance with federal and state policies for Medicaid and the Children’s Health Insurance Program (CHIP).
ESSENTIAL DUTIES AND RESPONSIBILITIES
Essential duties and responsibilities include the following. Other duties may be assigned.
Responsible for the integration of CNI Core Competencies into daily functions, including: commitment to integrity, knowledge / quality of work, supporting financial goals of the company, initiative / motivation, cooperation / relationships, problem analysis / discretion, accomplishing goals through organization, positive oral / written communication skills, leadership abilities, commitment to Affirmative Action, reliability / dependability, flexibility and ownership / accountability of actions taken.
Analyzes federal and state regulations / policies for Medicaid and CHIP reimbursements.
Conducts audits and leads audit teams to determine if reimbursements to medical providers were in compliance with regulations and policies.
Interacts with state personnel to schedule audits and explain findings.
Performs second-level reviews of audits conducted by fellow auditors.
Maintains the confidentiality of patient information in accordance with HIPAA regulations.
Conducts queries, and communicates data findings in written and oral reports, as well as presentations.
Travels within the U.S. to lead and conduct data processing reviews and audits.
Monitors pending reports, and takes appropriate action to bring issues to closure.
Supports training and development for the project as business need dictates.
Identifies and reports potential fraud discovered during the audit process.
Plans daily activities within the guidelines of company policy, job description and supervisor’s instruction in such a way as to maximize personal output. Responsible for aiding in own self-development by being available and receptive to all training made available by the company.
Responsible for keeping own immediate work area in a neat and orderly condition to ensure safety of self and coworkers. Will report any unsafe conditions and/or practices to the appropriate supervisor and human resources. Will immediately correct any unsafe conditions to the best of own ability.
Bachelor’s degree in a related field of study and a minimum of five (5) years relevant experience; or equivalent combination of education / experience. Master’s degree preferred. Experience working as a data analyst, auditor, quality control / assurance reviewer, or with Medicaid or other health insurance claims is preferred.
JOB SPECIFIC KNOWLEDGE / SKILLS / ABILITIES
Knowledge of Medicaid programs and Medicaid Management Information Systems (MMIS)
Working knowledge of Medicaid and/or CHIP and states’ claims processing systems
Operational knowledge and understanding of HIPAA regulations
Basic knowledge of Current Procedural Terminology (CPT) codes, International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-9 and 10-CM) codes, and Healthcare Common Procedure Coding System (HCPCS) codes
Detail-oriented with exceptional organization, analytical, investigative, problem-solving and critical thinking skills
Ability to collect, organize, evaluate and disseminate significant amounts of information
Ability to collect and analyze complex data, both narrative and statistical
Skilled proficiency in the use of Microsoft Windows and Office programs (i.e., Word, Excel, Outlook, PowerPoint, etc.)
Ability to effectively manage multiple projects and priorities, carry out day-to-day responsibilities and meet specified deadlines
Excellent leadership skills with ability to facilitate teamwork and coordinate efforts for the successful achievement of goals
Excellent verbal and written communications skills with ability to prepare a variety of written reports and presentations
Exceptional customer service skills with ability to adapt communications based on audience, both technical and non-technical
Excellent project management skills relative to all aspects of planning, organizing and coordinating the project with stakeholders
Ability to adapt to stressful environments and to utilize problem-solving skills in a demanding environment
Ability to effectively work both independently and in a team environment
Ability to travel at least 50% of the time
CERTIFICATES, LICENSES, REGISTRATION
Ability to work with mathematical concepts such as fractions, percentages, ratios, and proportions and to apply such concepts to practical situations.
Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, and/or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from managers, clients, customers, and the general public.