Please contact your Administrator to change your authorization settings.
Manage the vendors that are hired to perform Universal program review and audit functions for Priority Health. Oversee all activities associated with delivering an audit service from Statement of Work (SOW) creation to delivery of contract terms. Identify risk associated with incorrect payment decisions, audit outcome impacts, provider impacts, compliance or other health plan obligation that might involve actions by a vendor or the vendor's program operation. Assure oversight of efficient and correct vendor data exchange through other employees who execute them.
- Develops an annual risk assessment and audit plan to support the organization's Payment Integrity Strategy.
- Develop/sustain and engagement model between the Claims integrity function and other business units within the organization.
- Manages and coordinates substantive audits of medical claims, done internally and externally, for appropriateness of billing and payment, including investigation of inappropriate bundling/unbundling of services, erroneous and duplicate billings, data-entry omissions and errors, and inappropriate payments. Accurately summarizes and report findings to coordinate Provider communication and recovery of funds.
- Collaborates with Medical, Pharmacy, and Provider teams to determine the best course of action to align policies supporting cost containment activities.
- Establishes process for case assignment to review and respond to Provider appeals.
- Knowledge and understanding of plan products, payment methodologies, medical and payment policies.
- Reviews and provides feedback on provider agreements, member materials, and other internal documents impacted by the Payment Integrity program.
- Interviews, hires and manages staff to best prioritize and coordinate work efforts supporting efficient and effective cost containment activities specifically related to medical claims payments.
Required
- Bachelor's Degree or equivalent in Healthcare, Nursing, or Business
- 5 years of relevant experience working with Healthcare claim auditing or equivalent combination of; auditing, medical coding, healthcare revenue cycle, or regulatory (i.e., CMS & Medicaid) experience
- 5 years of in-depth understanding of provider payment methodologies and concepts (DRGs, capitation, RBRVS payments, APC, percent of charges, etc.)
- 5 years of relevant experience working with State and Federal regulations related to healthcare billing and coding
- Experience with health care claims
Preferred
- Direct experience in hospital or physician billing, or equivalent experience with a managed care payer
- Experience working with government programs including Medicare, Medicaid and FEHB
- CRT - Registered Health Information Technician (RHIT) - AAPC American Academy of Professional Coders Upon Hire or
- CRT - Registered Health Information Administrator (RHIA) - AHIMA American Health Information Management Association Upon Hire or
- CRT - Coding Specialist (CCS) - AHIMA American Health Information Management Association Upon Hire or
- CRT - Coding Specialist, Certified - Physician Based (CCS-P) - AHIMA American Health Information Management Association Upon or
- CRT - Professional Coder - AAPC American Academy of Professional Coders Upon Hire or
- CRT - Professional Coder, Certified - Payer (CPC-P) Upon Hire or
- CRT - Professional Coder, Certified - Hospital Outpatient (CPC-H) Upon Hire
- Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 10 lbs
- Waist to Waist > 5 lbs: Seldom up to 10 lbs
- Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs
- Waist to Overhead > 5 lbs: Seldom up to 10 lbs
- Bilateral Carry > 5 lbs: Seldom up to 10 lbs
- Unilateral Carry > 5 lbs: Seldom up to 10 lbs
- Pushing Force > 5 lbs: Seldom up to 10 lbs
- Pulling Force > 5 lbs: Seldom up to 10 lbs
- Sitting: Frequently
- Standing: Occasionally
- Walking: Occasionally
- Forward Bend - Standing: Seldom
- Forward Bend - Sitting: Occasionally
- Trunk Rotation - Standing: Seldom
- Trunk Rotation - Sitting: Occasionally
- Reach - Above Shoulder: Seldom
- Reach - at Shoulder or Below: Seldom
- Handling: Occasionally
- Forceful Grip > 5 lbs: Seldom
- Forceful Pinch > 2 lbs: Seldom
- Visual Acuity
[None = No; Seldom = Yes]: Seldom
Primary Location
SITE - Priority Health - 1239 E Beltline - Grand RapidsDepartment Name
PH - Payment Integrity LeadershipEmployment Type
Full timeShift
Day (United States of America)Weekly Scheduled Hours
40Hours of Work
8:00 a.m. to 5:00 p.m.Days Worked
Monday to FridayWeekend Frequency
N/ACURRENT COREWELL HEALTH TEAM MEMBERS - Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.
Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.
Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.
An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.
You may request assistance in completing the application process by calling 616.486.7447.
Beaumont Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, gender identity, sexual orientation, age, status as a protected veteran, or status as a qualified individual with a disability.