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The Payment Accuracy Analyst, Sr. is a key role responsible for supporting the Claim Editing team within UPMC Health Plan's Reimbursement Department. Functions include collaborating with external payment accuracy software vendors with regard to the implementation and maintenance of industry-standard clinical coding edits. Additionally, participates in cross-functional efforts including the Claims Operations, Systems Configuration, Medical Policy, & IT departments, and acts as a liaison between external vendors and internal stakeholders in the development and maintenance of claims payment and medical policy edits based on clinical, financial, and operations perspectives. The Payment Accuracy Analyst, Sr. is also accountable for ongoing report analysis that identifies areas of potential savings, along with ensuring payment accuracy and payor (i.e. Medicare, Medicaid) compliance.
This position will work in a hybrid work structure.
Responsibilities:
Conducts research and analysis for medical policy items for configuration of payor policy sourced edits; works with department leadership to determine how they can be configured to comply with UPMC Health Plan specific clinical and payment policy.
Advises management if edits are working as intended and supports decision with validation data.
Identifies and provides root-cause analysis of claim edit performance issues.
Provides subject matter expertise on coding, including collaboration with departments to support operations, implementation of financial initiatives, and other business objectives.
Coordinate the submission of IT requests associated with validations and the enhancement of reports/tools needed to maximize results.
Leads projects regarding monitoring, researching, and tracking changes as UPMC Health Plan payment and medical policy changes.
Create and maintain documentation aimed at promoting consistency in validations and claims workflow process improvements.
Stay current with policy changes, industry trends, and various payment models in healthcare.
Researches and responds to inquiries from senior-level leadership.
Evaluate claims coding rule change requests from clinical, financial, and claims operations perspectives. Includes providing regulatory and coding research, as well as changes stemming from contractual requirements, implementation activities, etc.
Maintain current industry knowledge of claim edit references including, but not limited to: AMA, CMS, and NCCI.
Work closely with the Manager and Director of Claim Editing in departmental functions and special projects.
Investigate and ensure code edit software customizations align with all lines of business, including employer-sponsored, individual, and government products.
Bachelor's degree and 4 years of relevant experience OR equivalent combination of education & work within healthcare payers/claims payment processing will be considered. Master's degree preferred
Current certified coder (CCS, CCS-P or CPC), or Registered Health Information Technician (RHIA/RHIT) preferred, but not required
Ability to interpret claim edit rules and references
Solid understanding of claims workflow and the ability to interpret professional and facility claim forms
Ability to apply industry coding guidelines to claim processes
Ability to perform audits of claims processes and apply root-cause
Significant experience with Excel for data analysis and creating reports for senior management
Familiarity with relational databases, such as Microsoft Access, SQL, etc.
Excellent verbal & written communication skills Licensure, Certifications, and Clearances: UPMC is an Equal Opportunity Employer/Disability/Veteran