Payment Accuracy Analyst

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

Your career starts now. We're looking for the next generation of health care leaders.

At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

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Responsibilities:

The Payment Integrity Analyst is responsible for conducting research and analysis and reviewing regulatory edits for federal and state statutes, regulations, provider manuals, bulletins, and other sources as needed to identify new overpayment edit concepts, as well as, validate all prospective and retrospective overpayment results.

Essential Functions:

• Identifies, develops, and implements new concepts that will target claim overpayment scenarios for each of ACFC's Medicaid and Medicare lines of business.

• Assists with ensuring that the current prospective and retrospective cost avoidance/ overpayment recovery processes are carried out within the established deadlines with a high level of accuracy

• Performs analysis on claims data, comparison reports, and State regulations for each state-specific edit on payer or state specific requirements

• Communicates effectively with each of our customers throughout the organization

• Reviews edit concept results for quality assurance and proof of concept validation

• Reviews all available sources including federal and state statutes, regulations, provider manuals, Provider contracts, and bulletins for changes to and/or new payment rules

• Identifies and documents changes to and/or new payment rules or language in the source document which may be utilized to update existing system edits or new system edits

• Contributes new ideas for improving existing processes

• Understands and applies all established SOPs for each of the teams processes

• Adheres to line of business specific procedures to perform routine functions based on department guidelines

Education/Experience:

• 3 to 5 years relevant experience ( healthcare claim reimbursement methodologies, state and federal payment policies, claims, data analysis)

• Bachelor's Degree or equivalent work experience.

• Active CPC

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

As a company, we support internal diversity through:

Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.