Job Information
UPMC Payment Accuracy Analyst in Pittsburgh, Pennsylvania
UPMC Health Plan is hiring a full-time Payment Accuracy Analyst to support the Hospital Reimbursement team. This role will work in a hybrid structure, with most time spent at home and some onsite presence at the US Steel Tower in Pittbsurgh.
The Payment Accuracy Analyst 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 vendor with regards 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 vendor 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 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.
Responsibilities:
Provide in-depth analysis of professional and facility claims routed to the manual claims validation queue based on new or updated edit logic.
Create and maintain documentation aimed at promoting consistency in validations and claims workflow process improvements.
Maintain current industry knowledge of claim edit references including, but not limited to: AMA, CMS, NCCI.
Advise management if edits are working as intended and support decision with validation data.
Aid and support to team members with reviewing complex or escalated member and provider appeals for accurate payment and processing in accordance with industry-standard coding guidelines.
Assist in monitoring, researching, and tracking changes as UPMC Health Plan payment and medical policy changes.
Identify and provide root-cause analysis of claim edit performance issues.
Conduct research and analysis for medical policy items for configuration of payor policy sourced edits; work with department leadership to determine how they can be configured to comply with UPMC Health Plan-specific clinical and payment policy.
Assist in the submission of IT requests associated with validations and the enhancement of reports/tools needed to maximize results.
Work closely with Manager and Director of Claim Editing in departmental functions and special projects.
Document daily claims performance for claim edits and advise management of any significant performance issues immediately.
Bachelor's degree and 2 years of relevant experience OR equivalent combination of education & work within healthcare payers/claims payment processing will be considered
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
Working knowledge of utilizing Excel for data analysis and creating reports for senior management
Excellent verbal & written communication skills Licensure, Certifications, and Clearances: UPMC is an Equal Opportunity Employer/Disability/Veteran