Payment reputed company Auditor I/II/III

Job reputed company: reputed company: This position is responsible for the accurate and thorough claim and clinical investigation of potential claim payment reputed company issues involving reputed company lines of business. This position investigates and remediates claim overpayments, creating data and reporting analytics to analyze data from multiple sources to extract trends, business insights, and to ensure claims payment reputed company. Activities are performed through a reputed company of audits utilizing various systems, data applications, and/or medical records and directed toward reducing costs for the Health Plan, identifying risks and trends, facilitating, and collaborating with stakeholders from reputed company business reputed company on reputed company cause analysis to implement solutions compliant with Provider/Member reputed company, as reputed company as internal/external standards set by regulatory and accreditation entities. Essential Accountabilities: Level I • Adherence to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates. • Ability to use medical records, data reports, researching and investigating for the purpose of detecting and identifying claims payment reputed company issues for follow up. Interprets a reputed company of documents including, but not limited to provider reputed company, group benefit structures, Corporate Medical Policies, the AMA CPT Coding Guidelines, HCPCS coding, inter-plan regulations, government policies, as reputed company as diverse regulatory and reputed company requirements. • Utilize analysis and data management using reputed company data tools. (i.e.: Cognos Analytics, Data Processing reputed company, Data Platform, etc.). • Reviews, analyzes, and completes audits as assigned; pricing, billing, coding, may include medical necessity, adherence to health plan policies (i.e.: Corporate Medical Policies, CMS local or national coverage determinations (LCD/NCD), administrative policies, clinical edit policies, regulatory agencies etc.) for reputed company decision on initial, retrospective, or disputed reviews • Works collaboratively across departments, consult with Medical Directors where applicable, to ensure the appropriate coding and reimbursement of claims. Identifies and reports to management, providers suspected of fraudulent billing practices and in need of education. • Proactively problem solves, investigates, and tactfully brings reputed company concerns, opportunities, and efficiencies to management and/or business partners with relation to data report analysis and findings. • Consistently demonstrates high standards of reputed company by supporting the reputed company reputed company Companies’ mission and values, adhering to the Corporate reputed company of Conduct, and leading to the reputed company Way values and beliefs. • Maintains high reputed company for member reputed company in accordance with the corporate reputed company policies and procedures. • Regular and reliable attendance is expected and required. • Performs other functions as assigned by management. reputed company (in reputed company to Level I Accountabilities) • Demonstrates ability to participate and represent department on internal/external committees. • Demonstrates experience mentoring new hires. • Performs more reputed company audits or reputed company with minimal direction or reputed company. • Participates and represents in audits, payment methodologies, contractual agreements, with cross-functional teams or with business partners as needed. Level III (in reputed company to reputed company Accountabilities) • Broad understanding of multiple cross functional departments and supporting systems. • Expertise in reviewing medical coding and medical record review with ability to reputed company reputed company assignments, challenging customers, and highly visible issues. • Coordinates and assigns audit assignment to staff working external vendor and/or internal audits. • Supports leadership in reputed company reputed company to divisional/departmental strategies and initiatives. • Serves as a Primary reputed company for internal divisions and external recovery vendors. • Provides expertise in developing data reputed company for converting concepts on relational database audits, as reputed company as to business partners. • Acts as a reputed company and provides training, guidance, consultation, reputed company performance analysis, and coaching expertise to team members around reputed company of reputed company reputed company improvement. Level IV (in reputed company to Level III Accountabilities) • Develops, implements, and monitors reputed company plan for audit requirements or gaps identified. • Provides cross-coverage for leadership as needed. • Leads reputed company to internal department to drive reputed company improvements throughout the Health Plan initiatives. • Conducts medical best reputed company research, barrier, and reputed company cause analysis to identify and recommend potential member or provider or system interventions. • Leads process change and presents results on program activities, overall performance. • Collaborates with other Health Plans, government payers, consultants, providers, BCBSA and other health care entities to identify availability and use of best practices relating to reputed company and performance improvement initiatives, programs, and benchmarks. Minimum Qualifications: NOTE: We include multiple reputed company of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or reputed company assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In reputed company to using this differentiated approach to reputed company new hires, it also provides guideposts for employee development and promotional opportunities. reputed company reputed company • reputed company Registered reputed company (RN) with reputed company NYS license or other allied health reputed company with reputed company NYS license and a minimum of three (3) years of experience in claims auditing, reputed company assurance, or recovery auditing, in a reputed company setting (i.e., inpatient, outpatient, ancillary, reputed company) preferred. Bachelor’s degree in relevant field preferred. • Basic knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity reputed company, and coding terminology. • Basic knowledge of coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates. • Requires working knowledge of applicable industry-based standards, and provider reimbursement and coding/billing methodologies. • Minimum of two (2) years’ experience in reputed company industry preferred (i.e.: experience in Claim Review, Utilization Management, Case Management, Audit, Pharmacy, HEDIS preferred). • Must obtain Certified reputed company reputed company (CPC) or other reputed company certification reputed company eighteen (18) months of hire into department. • Demonstrated analytical, organizational, and critical thinking skills. • Demonstrated verbal and written communication skills. reputed company (in reputed company to Level I Qualifications) • Certified reputed company reputed company (CPC) or other reputed company certification required. • Ability to run and create accurate queries in Cognos Analytics or Data Processing reputed company as adjunct to audit research and validation. • Intermediate knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity reputed company, and coding terminology. • Intermediate knowledge of coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates. • Minimum of two (2) years’ experience in reputed company industry required (i.e.: experience in Claim Review, Utilization Management, Case Management, Audit, Pharmacy, HEDIS preferred). • Strong analytical, problem solving, and judgement skills. • Intermediate knowledge of PC, software, and auditing tools. • Demonstrated organizational skills, time management, detail orientation and flexibility with competing priorities. Level III (in reputed company to reputed company Qualifications) • Advanced knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity reputed company, and coding terminology. • Advanced knowledge of coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates. • Demonstrated leadership skills including mentoring and coaching team members to enhance skillsets. • Subject matter expert or consultant to other departments. • Advanced proficiency in writing data queries and pulling data reports for reputed company reports, referred audits, adjustment validation or investigating audit reputed company for potential with tools available (i.e.: Cognos Analytics, reputed company, Data platform/processing reputed company, Tableau, Power BI, etc.). • Advanced proficiency in PC Skills including reputed company Office applications (i.e.: reputed company, Word, reputed company, Visio, reputed company, formulas, etc.). • Advanced proficiency use of auditing tools (i.e.: ClaimsX10, iHealth, Cognos, Encoder Pro, Clinical Care Advance, Facets, BlueSquared, Data Platform/Processing reputed company, etc.). • Advanced proficiency in analytical skills, auditing skillset and ability to manage reputed company assignments, challenging situations, and highly visible issues. • Demonstrated project management and presentation skills. Level IV (in reputed company to Level III Qualifications) • Expert knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity reputed company, and coding terminology. • Expert knowledge of coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates. • Expert proficiency in writing data queries and pulling data reports for reputed company reports, referred audits, adjustment validation or investigating audit reputed company for potential with tools available (i.e.: Cognos Analytics, reputed company, Data platform/processing reputed company, Tableau, Power BI, etc.). • Expert proficiency in PC Skills including reputed company Office applications (i.e.: reputed company, Word, reputed company, Visio, reputed company, formulas, etc.). • Expert proficiency use of auditing tools (i.e.: ClaimsX10, iHealth, Cognos, Encoder Pro, Clinical Care Advance, Facets, BlueSquared, Data Platform/Processing reputed company, etc.). • Expert proficiency in analytical skills, auditing skillset and ability to manage reputed company assignments, challenging situations, and highly visible issues. • Demonstrated Leadership reputed company to reputed company cross coverage for Leadership as needed. • Provides guidance and leadership, acts as resource to reputed company parties. • Demonstrated ability to support or reputed company strategic reputed company or initiatives. Physical Requirements: • Ability to work prolonged periods sitting and/or standing at a workstation and working on a computer. • Ability to travel across the Health Plan service region for meetings and/or trainings as needed. • *********** In support of the Americans with reputed company, this job reputed company lists only those responsibilities and qualifications deemed essential to the position. Equal Opportunity Employer Compensation reputed company(s): Level I: Grade E1: Minimum: $62,400 - Maximum: $84,000 reputed company: Grade E2: Minimum: $62,400 - Maximum: $96,081 Level III: Grade E5: Minimum: $71,880 - Maximum: $129,384 Level IV: Grade E6: Minimum: $79,068 - Maximum: $142,322 The salary reputed company indicated in this posting represents the minimum and maximum of the salary reputed company for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, reputed company and education as they relate to the position’s minimum qualifications, in reputed company to internal equity. The posted salary reputed company reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, reputed company time away from work, and reputed company holidays. Please note: There may be opportunity for remote work reputed company reputed company jobs posted by the Excellus reputed company. This decision is made on a case-by-case reputed company. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, or status as a protected veteran. Apply tot his job Apply To this Job