Job Description

1. Research and Analysis
   • Serve as contact for external vendors and internal departments to support operations and payment integrity activities.
   • Research and respond to low to high priority complex internal and external inquiries.
   • Analyze and coordinate vendor performance reviews using KPIs (e.g., recovery yield, turnaround time, false positive rates, provider abrasion).
   • Coordinate reconciliation of vendor invoices, validating against contractual terms, recoveries, and performance metrics.
   • Is proficient at utilizing a variety of resources including but not limited to on-line information files and databases, Medicare/other plan guidelines, plan certificates, provider contracts.
   • Update and create CES and Cotiviti pend resolutions.
2. Business Analysis & Reporting
   • Analyze operational and financial data to identify trends, savings opportunities, and anomalies.
   • Assess business impact of new edits and changes in medical reimbursement policies/guidelines.
   • Initiate, develop, coordinate and implement cost/benefit analysis of claims processing.
   • Develop documentation, including cost/benefit and business impact analysis and recommendations to implement and/or improve claims processing.
   • Collaborate with IT and data teams to validate extracts, reconciliations, and vendor reporting feeds.
3. Operational & Strategic Alignment
   
   • Recommend process improvements to increase efficiency and results.
   • Identification and resolution of issues and trends as a result of researching and responding to implementation requests, problem reports, and inquiries.
   • Support cross-functional projects, including audit response, regulatory requests, and enterprise cost-containment strategies.
   • Act as SME (subject matter expert) on payment integrity activities, workflow design, and best practices.
4. Performs all other miscellaneous responsibilities and duties as assigned or directed.

1. Bachelor's degree or equivalent combination of education and work experience.
2. Two years of related work experience.
3. Understanding of HMSA's business practices, benefit plans, medical and payment policies
4. Excellent organizational and analytical skills
5. Knowledge of regulations and standards: HIPAA, state, and federal regulations, including CMS, NCQA, and state DOI requirements.
6. Basic working knowledge of Microsoft Office applications including, but not limited to Word, Powerpoint, Outlook and Excel.