|Employer:||Medica Health Plans
|Skills:||Coding,claims,clinical review,COSMOS & UNET,Reimbursement
|Required Experience:||3 to 4 years
Medica’s Payment Integrity Clinical Analyst is responsible for executing a claim recovery strategy which includes the analysis of claims data for identifying cost containment opportunities both with internal and external partners. Our Clinical Analysts also work to review and analyze recommendations for recovery found in waste and abuse recovery audits, and plays an integral role in ensuring claim integrity as this position supports all recovery efforts for the Claims Operations team.
The Clinical Analyst will also review recommendations for recovery to determine if it aligns with state and federal compliance policies, corporate reimbursement policies, contract compliance, and regulatory codes (CPT), as well as pre-authorizations and/or medical records. The analyst will also have direct responsibility to work with our vendors to ensure any corrections, recommendations or issues are resolved to satisfaction.
Other responsibilities include:
- Analyzing and identifying trend recovery patterns to look for process improvement opportunities and submitting recommendations in writing to the internal customers and external vendors in which the reviews are being performed.
- Representing Recovery Claims Operations at interdepartmental and external departmental meetings.
- Managing and supporting various large projects throughout the year including but not limited to waste, abuse, and recovery.
- Collaborating with Medica staff from various departments as well as external clients to ensure prompt and appropriate action is taken regarding any claims in question.
Ideal candidates will have a strong understanding of healthcare, medical claim billing standards, recovery practices, as well as vendor management, operational functions and company operations. In addition, this position requires the ability to actively manage multiple projects simultaneously and candidates will need strong organizational, analytical, and problem solving skills.
- Bachelor’s degree or equivalent combination of education and work experience
- 3+ years recovery and/or clinical auditing/analytic experience
- CPT coding experience
- Health care claims experience
- Background in clinical review of claims
- Certified Professional Coder – Physician (CPC-P) strongly preferred
- RN or LPN License strongly preferred
Skills & Abilities:
- Must have strong written and verbal communications skills, meeting facilitation skills, interpersonal skills, attention to detail, organizational and prioritizing skills
- Knowledge and understanding of health care industry and billing practices
- Process improvement experience preferred
- Understanding of provider contracting and claims processing
- Detail oriented/analytical thinking, creative - thinks outside the box
- Strong project management skills and data analysis skills
- Ability to identify trends in data and clearly articulate them
- Understanding of COSMOS & UNET capabilities and an understanding of reimbursement methodologies
- Presentation skills to a broad audience