Under limited supervision, leverages payment integrity program output to increase accuracy of claims payments and efficiency while minimizing associated program costs for the Company and its self-funded groups. Compares internal payment integrity program output to that of outsourced vendors and generates program benchmarks. Partners with management team to present analytical findings and design payment integrity/review programs and tools to maximize financial and personnel resources.
Designs and generates advanced queries and analysis on payment integrity vendor performance, provider payment trends and executive claim trend requests
Utilizes data analysis to evaluate claims savings concepts for internalization, improvements in payment trends or adjudication efficiency
Analyzes and works directly with third party organizations to facilitate payment integrity vendor claims savings invoicing and provider data transmissions to assure accuracy
Creates systematic solutions for departmental initiatives utilizing claims savings data to maximize claims payment accuracy and savings. Analyzes user requirements; designs, tests and implements systematic solutions; provides ongoing support to users
Performs data analysis in an effort to minimize duplication of review efforts across internal departments and vendors
Orients, trains and assists more junior staff. Creates training programs and procedural documentation for the department and ensures they are kept up to date
Performs other duties as assigned
- Bachelor's degree in finance, business or healthcare administration, or related area of study. In lieu of degree, may consider equivalent combination of education/training and relevant experience
Master's degree preferred
5 years progressive experience as a Payment Integrity Analyst or equivalent financial and data analysis experience in health insurance operations (i.e. claims processing, billing and coding)
Certified Medical Audit Specialist Certification (CMAS) preferred
Knowledge of medical claims adjudications systems, functionality and limitations
Knowledge of medical claims payment integrity program trends
Advanced DB2, SQL, SQL Server, Microsoft Visual Basic, SAS skills and familiarity with mainframe-based claims adjudication systems.
Advanced Microsoft Office skills including Access
Ability to interpret and articulate complex business and financial concepts to various audiences including executives
Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:
A Great Place to Work:
- Top Workplace in Northeast Ohio. Year after year we've received this recognition!
- On-site wellness center at most locations. Enjoy personal trainers, towel service, locker room, weight room, elliptical machines, and a variety of classes!
- On-site cafeteria serving hot breakfast and lunch, at most locations. Choices ranging from salad bar, made to order, hot and cold sandwiches, or a variety of entrees cooked fresh daily. Convenience store at most locations
- Employee discount program. Discounts at many places in and around town, just for being a Medical Mutual team member
- Business casual attire
Excellent Benefits and Compensation:
- Competitive compensation plans
- Employee bonus program
- 401(k) with company match and an additional company contribution
- Excellent medical, dental, vision, and disability insurance
An Investment in You:
- Career development programs and classes
- Mentoring and coaching to help you advance
- Education reimbursement up to $5K per year
About Medical Mutual:
We strive to create peace of mind. Our customers can trust us to do things right and to help them get value from their health plan. We're the largest health insurer in Ohio and for over 85 years, we've been serving our members and the Ohio communities where they live and work. Medical Mutual is a Top Place to Work in Northeast Ohio with exceptional career opportunities that offer challenge, growth and a great work/life balance. We want talented, innovative, and driven people to help us continue to be the best health insurance choice of Ohioans and help make Ohio the best it can be! Our headquarter building is located in the heart of downtown Cleveland and we have multiple offices throughout the state. Join us at one near you!
At Medical Mutual we celebrate differences and are mutually invested in our employees and our community. We are proud to be an Equal Employment Opportunity and Affirmative Action Employer. Qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, veteran status, or disability status.
We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.
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