Payment Integrity Representative

Summary

Responsible for reviewing, maintaining, and analyzing underpayment records and managed care contracts to ensure Sanford is paid according to contract terms for system billing, maximizing reimbursement, and maintaining compliant practices.

Job Description

• Develop, document and oversee standard operating procedures in OneNote to ensure consistency in business rules applied in claim adjudication.
• Possess in-depth understanding of the reimbursement techniques and strategies.
• Knowledge in reimbursement/payment classification systems, fee schedules and managed care contracts.
• Knowledge of Remark and Reason codes sent from payors as well as reading a remittance advice.
• Responsible for the appeals related to underpayments & overpayments according to Sanford's internal guidelines.
• Work with reimbursement analysis and testing by payor, analyze trending of managed care issues by payor, and assist in reviewing managed care activity in the system.
• Interpret and analyze complex managed care contracts and schedules to ensure payments received as contracted.
• Analyze information objectively and draw a rational conclusion.
• Complete extensive research to determine if claims are being paid correctly per separate guidelines that payors have that are not part of Sanford contracts.
• Lift up payment processing policies that are being deployed by the payors to Sanford Contracting team.
• Identify errors by operational departments, research and provide guidance on how coverage should be set up.
• Identify and communicate enrollment issues when new payors are brought on.
• Identify systemic issues with payor claim systems by investigating and finding patterns of claim variances.
• Facilitate education and distribution of relevant information to internal departments and payors.
• Call payors to help identify the issue on a particular underpayment, being able to collate well for final resolution.
• Support billing and finance in developing and conducting analysis and reporting to aid operational decision making.
• Cultivate positive working relationships with management, staff and other departments.
• Skilled in negotiation, able to build consensus while managing the delicate managed care relationships between system and payors.

Qualifications

Associate degree in healthcare or business related field required or in lieu of education will accept a minimum of three years prior healthcare revenue cycle experience. Experience working with Excel spreadsheets required. Minimum two years prior healthcare experience with an understanding of healthcare reimbursement preferred.