Company Statement
ConnectiCare is a leading health plan in the state of Connecticut. ConnectiCare’s mission is to make it easy for members to get the care they need. A local company for over 35 years, ConnectiCare has a full range of products and services for businesses, municipalities, individuals and those who are Medicare-eligible. A subsidiary of EmblemHealth, ConnectiCare leads the individual and small group markets in the state, and is ranked among the top commercial health plans in the nation, according to the National Committee for Quality Assurance.
We’re looking for individuals who want to make a difference in the communities we serve. If you want to join a local team and help change the way health care is delivered, ConnectiCare is the place for you.
Senior Payment Integrity Analyst
Summary of Job: To act as point person for Payment Integrity, Provider Reimbursement and external vendors responsible for performing Payment Integrity activities to include validation of finding and the identification, development, completion of Payment Integrity initiatives to drive incremental savings for the organization. This position would additionally provide support in claims and data analytic methods to identify overpayment prevention opportunities. Responsible for identifying and resolving high risk claims and remediation of any identified incorrect payments resulting from aberrant provider billing practices and internal payment errors.
Responsibilities:
• Responsible for payment integrity solutions focused on improving claim payment accuracy and reducing overall medical spend.
• Responsible for overseeing and supporting the Issue Resolution Workgroup with tracking, triage and resolution working collectively as a SME with business owners across the organization.
• Shares/Coordinates information sharing about erroneous, duplicative, wasteful, and fraudulent claim payment among all internal business teams involved in the review and audit of payment accuracy and makes recommendations for cost control.
• Conduct research and root-cause analysis of potential overpayments and initiate corrective action plans, ultimately leading to additional internal recovery and prevention savings.
• Supports and performs routine and special audits/reviews of par and no-par provider claims to determine payment accuracy with information shared from internal/external datamining, predictive analytics and FAMS.
• Use Excel, Access and SQL to report and take large volume of claims data and reduce to concise actionable claim data sets.
• Works with minimal guidance; understands when escalation is appropriate and works with business owners for escalated issues
• Post all refunds to appropriate systems in timely and accurate manner, including the processing of vendor invoices.
• Analyze and work claims in Service Matrix baskets to ensure timely resolution.
• Ensures timely performance measurement and assists in the identification and implementation of improvement initiatives.
• Performs other related projects and duties as assigned.
Qualifications:
• Requires Bachelor’s Degree in Finance, IS, computer science or equivalent work experience
• At least 5 years of proven data mining experience in a healthcare claims environment
• Broad cross-functional healthcare experience as well as specialized functional healthcare expertise
• Strong understanding of CPT, HCPCS and ICD9 coding required
• Ability to turn documented root cause analysis findings into actionable reports
• Ability to conduct sound root cause analysis as it relates to claim overpayments
• Strong analytical, influence, conflict resolution and negotiation skills
• Demonstrated consulting and facilitation skills
• Excellent oral and written communication, interpersonal and presentation skills
• Proactively learns new systems, tools or content areas to achieve results
• Technologically literate- familiar with IT focused framework, systems and methodology
• Microsoft Office Suite proficiency: Word, PowerPOint, Excel and Visio
• AMISYS system knowledge strongly preferred
• Microsoft Office Suite proficiency: Word, PowerPoint, Excel, Access & Visio
• Knowledge of relational databases especially MS Access and SQL preferred
• Ability to be flexible and adaptable in a team environment
ESSENTIAL JOB REQUIREMENTS:
• Primarily sedentary
• Must be able to use standard office equipment
EEOC Statement
We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.