Post-Pay Compliance Clinical Analyst
The Post-Pay Compliance Clinical Analyst is responsible for executing a recovery strategy that has been approved by the Manager and Director of Claims Operations. The process will consist of approving and rejecting recommendations for recovery found in waste and abuse recovery audits. The Post-Pay Compliance Clinical Analyst is responsible for reviewing the recommendation to determine if it aligns with state and federal compliance policies, corporate reimbursement policies, contract compliance, and regulatory codes (CPT), as well as pre-authorizations and/or medical records. The analyst will also have direct responsibility to work with our vendors to ensure any corrections, recommendations or issues are resolved to satisfaction.
This position plays an integral role in ensuring claim integrity as it supports all recovery efforts for the Claims Operations team.
Fulfilling the duties of this position accurately, effectively and in a timely manner directly affects the recovery of claim payments made due to wasteful and abusive billing patterns.
The Post-Pay Compliance Analyst will analyze and trend recovery patterns to look for process improvement opportunities and will submit recommendations in writing to the internal customers and external vendors in which the reviews are being performed and report to management.
This position will also be responsible for representing Recovery Claims Operations at interdepartmental and external departmental meetings. Various large projects throughout the year are to be managed by, or largely supported through this position included but not limited to, waste, abuse and recovery. This position must collaborate with Medica staff from various departments as well as external clients to ensure prompt and appropriate action is taken regarding any claims in question. This position must also have a strong understanding of healthcare, medical claim billing standards, recovery practices, as well as vendor management, operational functions and company operations to be successful in the role. In addition, this position requires the ability to actively manage multiple projects simultaneously and strong organizational, analytical and problem solving skills. Solid verbal and written communication and interpersonal skills are required to effectively collaborate with other internal Medica departments as well as external parties.
- Recovery Review and Mobilization
- Identify and report results and opportunity for improvement regarding recovery findings
- Provider Education & Appeals
- System Enhancements & Training
- Bachelor’s or Associate's Registered Nurse Degree
- 3+ years recovery and/or clinical auditing/analytic experience
Specific types of Experience:
- CPT coding experience
- Health care claims experience
- Background in clinical review of claims
- Hospital nursing
- Certified Professional Coder (CPC)
- COSMOS (United Healthcare only system) claims processing experience preferred
- Current license as an RN in the state of Minnesota
Skills and Abilities:
- Must have strong written and verbal communications skills, meeting facilitation skills, interpersonal skills, attention to detail, organizational and prioritizing skills
- Knowledge and understanding of health care industry and billing practices
- Process improvement experience preferred
- Understanding of provider contracting and claims processing
- Detail oriented/analytical thinking, creative - thinks outside the box
- Strong project management skills and data analysis skills
- Ability to identify trends in data and clearly articulates them
- Understanding of COSMOS & UNET capabilities and an understanding of reimbursement methodologies
- Presentation skills to a broad audience