Note: The job is a remote job and is open to candidates in USA. CERIS, a division of CorVel Corporation, provides clinical expertise and cost containment solutions focused on accuracy and transparency in healthcare payments. The Payment Integrity Analyst II reviews pre- and post-pay claim audits, applies client policies and CMS guidelines, analyzes documentation, and completes audits and appeals using clinical judgment and analytical skills.
Responsibilities
- Reviews, analyzes, and completes internal audits and/or appeals in accordance with client policy, CMS guidelines and industry standards in clear and professional written communication
- Ability to use clinical judgement and analytical skills to appropriately review documentation submitted for claim audits
- Utilize clinical judgement to appropriately interpret and apply client policies along with CMS guidelines as it relates to reviews done by CERIS such as itemized bill, DRG and/or specialty audits
- Utilize applicable tools and resources to complete internal audits and/or appeals
- Timely completion of internal audits and/or appeals
- Attends Clinical Team Meetings, All Company Meetings, Education Opportunities, Trainings, and other potential meetings
- Additional duties as assigned
Skills
- Ability to demonstrate understanding of CMS and commercial payer policy in written and verbal format
- Strong understanding of claims processing, ICD-10 Coding, DRG Validation, Coordination of Benefits
- Strong understanding of healthcare revenue cycle and claims reimbursement
- Proficient in Microsoft Office including Pivot Tables and Database Management
- Comfortable interfacing with clients and the C-Suite
- Demonstrate ability to manage multiple projects, set priorities and adhere to committed schedule
- Strong interpersonal skills and adaptive communication style, complex problem solving skills, drive for results, innovative
- Excellent written and verbal communication skills
- Proven track record of delivering concrete results in strategic projects/programs
- Strong analytical and modeling ability and distilling data into actionable results
- Superb attention to detail and ability to deliver results in a fast paced and dynamic environment
- Must maintain a current LPN, LVN and/or RN licensure
- 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
- 1+ years healthcare revenue cycle
- 1+ years of relevant experience or equivalent combination of education and work experience
- 1+ years hospital bill audit
- Preferred experience with health insurance denials and/or appeals, payer audits, or vendor audits
- Bachelor's degree in healthcare or related field preferred
Benefits
- This is a remote position.
- For full-time regular employees: Medical (HDHP) w/Pharmacy
- For full-time regular employees: Dental
- For full-time regular employees: Vision
- For full-time regular employees: Long Term Disability
- For full-time regular employees: Health Savings Account
- For full-time regular employees: Flexible Spending Account Options
- For full-time regular employees: Life Insurance
- For full-time regular employees: Accident Insurance
- For full-time regular employees: Critical Illness Insurance
- For full-time regular employees: Pre-paid Legal Insurance
- For full-time regular employees: Parking and Transit FSA accounts
- For full-time regular employees: 401K
- For full-time regular employees: ROTH 401K
- For full-time regular employees: paid time off
- Plenty of career advancement opportunities
Company Overview