Conducts claim audits
looking for overpayments, including potentially preventable readmissions, unnecessary
procedures, excessive units billing and potential fraud waste and abuse.
Perform trend analysis
of claims for Payment Integrity and quality assurance.
Work with various other
areas within CCA, such as Contracting, FWA and Clinical teams to ensures
clarity and accuracy in all phases of the payment integrity claims process.
reviewing medical records and claims as needed to ensure payment accuracy,
adherence to payment policies, regulations and provider contract obligations.
Ensures optimal system
coding that adhere to all billing compliance standards.
Ensures timely and
accurate communications of medical necessity review results to the original
requester (e.g., primary care team, specialty providers, vendors) in compliance
with regulatory and contractual requirements. May require collaboration with
internal business partners.
Manages the process for
escalated reviews in accordance with Standard Operating Procedures.
departmental and organizational policies and procedures as well as regulatory
requirements and other
regulatory reporting needs are met.
What we are looking for
Diploma in Nursing,
Associate’s Degree in Nursing, Bachelor's Degree preferred
5+ years clinical/auditing and/or utilization
years’ experience working with a health plan, performing audits to ensure
payment integrity is maintained based on appropriate rules, regulations and
corresponding contract language.
Nurse licensed in the Commonwealth of Massachusetts in good standing.
required to pass CCA’s credentialing process.
Experience with Dual
Eligibility, Medicare, Medicaid and Mass Health.
Knowledge of CPT,
ICD10, HCPCS or other coding structures are required.
Knowledge of UB-04s, CMS 1500 forms, and itemized statements
Demonstrated ability to
establish and manage performance and outcome metrics.
and communication skills with the ability to partner effectively across the
organization and with external partners.
InterQual criteria applied to procedures
individualized complex care plans
Understands and recognizes medical and insurance terminology
thinker and tactical performer
management skills with the demonstrated ability to handle multiple projects.
Ability to establish
and maintain positive and effective work relationships with internal staff,
external vendors, and state and federal agencies
Proven skills and
judgment necessary for independent decision-making.
organizational, time-management and problem-solving skills
Ability to influence