19 payment integrity analyst ii jobs found

The Payment Integrity Analyst is responsible for accurately reviewing and completing pre- and post pay claim audits based on client, policy, industry standards and/or CMS guidelines.   ESSENTIAL FUNCTIONS & 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 Use 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, company meetings, educational opportunities/trainings, and other meetings Additional duties as assigned   KNOWLEDGE & SKILLS: Ability to use clinical judgment and analytical skills for...

The Payment Integrity Analyst is responsible for accurately reviewing and completing pre- and post pay claim audits based on client, policy, industry standards and/or CMS guidelines. This is a remote position. ESSENTIAL FUNCTIONS & 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 Use 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, company meetings, educational opportunities/trainings, and other meetings Additional duties as assigned   KNOWLEDGE & SKILLS: Ability to use clinical judgment and...

The Payment Integrity Analyst is responsible for accurately reviewing and completing pre- and post pay claim audits based on client, policy, industry standards and/or CMS guidelines.   ESSENTIAL FUNCTIONS & 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 Use 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, company meetings, educational opportunities/trainings, and other meetings Additional duties as assigned   KNOWLEDGE & SKILLS: Ability to use clinical judgment and analytical skills for...

The Indemnity Claims Specialist manages within company best practices lower-level, non-complex and non-problematic workers’ compensation claims within delegated limited authority to best possible outcome, under the direct supervision of a senior claims professional, supporting the goals of claims department and of CorVel. This is a hybrid position. ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Receives Workers’ Compensation claims, confirms policy coverage and acknowledgment of the claim Determines validity and compensability of the claim Establishes reserves and authorizes payments within reserving authority limits Manages non-complex lost-time workers’ compensation claims under close supervision Communicates claim status with the customer, claimant and client Adheres to client and carrier guidelines and participates in claims review as needed Assists other claims professionals with more complex or problematic claims as necessary...

The Procurement Analyst plays a critical role in supporting Enhanced Bill Review Programs by securing essential medical documentation, including itemizations and medical records needed to process claims accurately and efficiently. This position involves proactive outreach to providers, managing inbound inquiries, and ensuring all documentation meets quality and compliance standards, including HIPAA regulations. The Procurement Analyst is detail-oriented, organized, and thrives in a fast-paced environment where meeting production goals and collaborating with team members are key to success. This is an onsite position. ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Spend approximately 80-85% of the shift making outbound calls to providers to obtain required information; may also send email or fax requests Respond to inbound calls regarding claim status and related inquiries Maintain accurate records of all communications between the company, providers, and...

The Provider Management Analyst is responsible for verifying provider information and requests for documentation to audit claims including but not limited to itemized bills, medical records, UB04’s, HCFA’s, etc. Responsibilities include verifying patient information, provider contact information, and client information for accuracy to ensure proper delivery of requests.   ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Communicate with respective leadership on any issues or problems identified Maintain production standards, production requirements, and quality of work Assist coworkers, supervisor, or management to accomplish product goals; report potential issues in a proactive manner Timely forward misdirected requests to the correct recipient Ensure strict confidentiality of all medical records, PHI, and PII Outbound calling may be needed Additional duties as assigned KNOWLEDGE & SKILLS: Ability to work independently...

The Itemization Review Nurse provides a summary and analysis of items by reviewing all charges on a UBIB submitted by a medical facility to determine accuracy of billed charges. This is a remote position. ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Collects supporting data and analyzes information to make decisions regarding accuracy of billing Appropriately documents work and final conclusions in designated computer program Understanding of Surgical Implants Meets department's expectations and standards  Additional duties as assigned   KNOWLEDGE & SKILLS: Understanding of Itemization Review for designated clients Understanding of CERIS systems and Data Base informatics Understanding of HIPAA regulations Exceptional organizational skills with the ability to handle stressful situations and adapt accordingly Demonstrated leadership skills; ability to work with Leadership Team(s) within a positive team environment...

The Repricing Quality Assurance Analyst is responsible for reviewing, analyzing, and monitoring repricing audit data across multiple platforms to ensure accuracy, compliance, and efficiency. Works closely with internal teams to maintain contractual and organizational standards, enhance operational effectiveness, and improve client satisfaction. This is a remote position. ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Identify and resolve quality issues within repricing processes Develop and implement QA policies and procedures Monitor compliance with pricing guidelines and contractual requirements Investigate repricing discrepancies and apply corrective actions Prepare QA reports and documentation Collaborate with stakeholders to align quality objectives Provide training and guidance on repricing standards Conduct risk assessments to mitigate potential errors Maintain confidentiality of client data, PHI, and PII Additional duties as assigned...

The Recovery Supervisor is responsible for analysis and monitoring of claims audit data across multiple platforms. The Supervisor manages and prioritizes staff daily work assignments necessary to ensure the timely and accurate processing of internal and external requests, interdepartmental quality audits and claims processing. Additionally, the supervisor works to reduce response timeframes and mitigate future inquiries or escalations by being proactive, taking ownership of challenges, and formulating solutions to improve overall department activities while maintaining a focus on improving how we deliver service to our customers.     This is a remote position. ESSENTIAL FUNCTIONS AND RESPONSIBILITIES: Manage team performance by setting and communicating standards and deadlines, measuring results, and providing feedback. Maintain positive morale by leading the team through example and accountability with a focus on helping each member achieve their best performance...

The Workers’ Compensation Claims Specialist manages within company best practices lower-level, non-complex and non-problematic workers’ compensation claims within delegated limited authority to best possible outcome, under the direct supervision of a senior claims professional, supporting the goals of claims department and of CorVel. This is a hybrid position. ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Receives Workers’ Compensation claims, confirms policy coverage and acknowledgment of the claim Determines validity and compensability of the claim Establishes reserves and authorizes payments within reserving authority limits Manages non-complex lost-time workers’ compensation claims under close supervision Communicates claim status with the customer, claimant and client Adheres to client and carrier guidelines and participates in claims review as needed Assists other claims professionals with more complex or problematic claims as...

The Quality Control Nurse is responsible for ensuring and maintaining MCS Bill Review database integrity.  Ensures timely application of QC protocols to meet production standards. This is a remote position. ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Analyses itemization line item descriptors from hospital billing entered Verifies line item data sets for completeness, correctness and understandability Maintain the integrity of each provider chargemaster within Scheck Maintains consistent communications with the Data Entry Analyst on line item entries Maintains constant communications with the Medical Review Department regarding unusual billing practices and discovery of potential errors Maintain 100% accuracy of data set(s) PRIOR to moving files to the next department to meet production and turnaround time requirements Maintain HIPAA compliance in all aspects of communications Comply with all safety rules and regulations during work hours in conjunction with...

The Revenue Cycle Specialist is responsible for analysis and monitoring of claims audit data across multiple platforms. Performs various follow-up activities to ensure the accuracy and appropriateness of reimbursement made to healthcare providers. Responsibilities include identifying payment variances and working internally and externally to resolve such issues. This is a remote position. ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Analyze and adjust/reprice claims to ensure accurate reimbursement rates in accordance with contractual agreements and payer guidelines Establishing and maintaining accurate pricing structures and rules to ensure competitive and profitable pricing strategies across various claims  with precision Identifies errors in reconciliation files across multiple work streams and business units for multiple sites and with external partners. Performs contract and reimbursement variance analysis. Analyzes claims data to identify...

The CERIS Operations Manager is responsible for overseeing all aspects of the department including Personnel Hiring, Quality Assurance of Product, Workflow, Maintaining the tracking of and accountability of staff regarding production standards and department expectations. Works collaboratively with other department managers to achieve departmental requirements and goals.  This is a remote position. ESSENTIAL FUNCTIONS & RESPONSIBILITIES:  Ensures timely and accurate communication of information, in written and electronic forms, that are directed to internal company contacts, clients and providers Directs a designated group of employees in their day-to-day operations Monitors employee and unit quality control Ensures daily compliance with metrics Tracking and reporting of department metrics to Director of Operations on a monthly basis or as required Handles scheduling and monitoring of staff’s attendance Ensures timely distribution of...

The Setup Team Lead is responsible for assisting and supporting   the Setup Supervisor with ensuring   the Setup Team meets protocol. This role will assist with supervisory functions when the Setup Supervisor is absent. The Setup Team Lead is responsible for ½ production. This is a remote position.   ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Must maintain ½ production quota Organize and distribute claims according to established priority Provide guidance to analysts, aiding with resolution of problems or questions Process complex/problematic claims according to protocol Maintain production standards and production requirements Comply with standard protocol for processing problem claims Function as liaison between analysts and clients Professionally communicate with other offices and internal departments Train new team members Assist co-workers, supervisor and management in accomplishing production goals Maintain HIPAA compliance in all aspects of...

The Procurement Coordinator is responsible for maintaining a consistent workflow by distributing claims to Procurement Analysts. This role keeps track of current volume on an individual basis to ensure even distribution throughout the department. The Procurement Coordinator is a detail-oriented contributor performing   Quality Control (QC) reviews for incoming and outgoing files. This is a remote position.   ESSENTIAL FUNCTIONS & RESPONSIBILITIES: File distribution to all Procurement staff (initial distribution and redistribution as necessary) QC/Review of incoming and outgoing files  for accuracy before distribution to end users Generate   and   send   mail, e-mail, reports, and forms to inter-office personnel; may as needed send reports to clients, managers, and other CorVel offices Document procedures and all client-specific protocols Additional duties as assigned   KNOWLEDGE & SKILLS: Proficient in Microsoft Office...

The Procurement Team Lead position is 50% production and 50% assisting and supporting direct supervisor with ensuring the team meets protocol, as well as performing supervisory duties during the supervisor's absence. This is an onsite position. ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Monitor/Audit and reports for Procurement and clients Monitor/Audit files in Procurement staffs individual service queues via Management Console Tool for accuracy and timely claim processing Assist with Procurement QC queue tickets during high volume times Assist team members with all questions and concerns Answer emails and phone calls from both Procurement and other internal departments and also externally from Clients/Providers regarding any claims processing concerns Additional duties as assigned   KNOWLEDGE & SKILLS: Exceptional organizational skills Ability to work independently and in a team environment Ability to work in a fast paced/production...

The Vice President of Claims will execute on the strategic goals and vision of the company. This includes the management and Development of staff and revenue. This role requires a high level of analytical, interpersonal, and organizational skills and will be responsible for claims quality, customer satisfaction and retention.  The VP of Claims  will also identify, facilitate and participate in essential strategic projects  for operational improvement as well as support and directly participate in sales presentations/RFP responses and the development of opportunities to  promote  the company’s overall growth.  This is a hybrid position.   ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Position shares responsibility for meeting and exceeding market profit and revenue goals annually Position shares responsibility to grow market share through accountability for customer satisfaction and retention Participates in Marketing and Sales presentations of prospective...

The Itemization Review Nurse provides a summary and analysis of items by reviewing all charges on a UBIB submitted by a medical facility to determine accuracy of billed charges. This is a remote position.  ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Collect supporting data and analyze information to make decisions regarding accuracy of billing Appropriately document work and final conclusions in designated computer program Understanding of Surgical Implants Understanding of CERiS systems and Data Base informatics Capability to meet department expectations and standards Be a team player working with Leadership Team(s) within a positive team environment Additional duties/responsibilities as assigned Comply with all safety rules/regulations, in conjunction with the Injury and Illness Prevention Program (“IIPP”), as well as maintain HIPAA compliance   KNOWLEDGE & SKILLS: Exceptional organizational, strategic and critical...

The Provider Management Analyst is responsible for verifying provider information and requests for documentation to audit claims including but not limited to itemized bills, medical records, UB04’s, HCFA’s, etc. Responsibilities include verifying patient information, provider contact information, and client information for accuracy to ensure proper delivery of requests. This is a remote position. ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Communicate with respective leadership on any issues or problems identified Maintain production standards, production requirements, and quality of work Assist coworkers, supervisor, or management to accomplish product goals; report potential issues in a proactive manner Timely forward misdirected requests to the correct recipient Ensure strict confidentiality of all medical records, PHI, and PII Outbound calling may be needed Additional duties as assigned KNOWLEDGE & SKILLS: Ability to work independently...