Payment Integrity Analyst II

Description The Payment Integrity Analyst is responsible for accurately reviewing and completing pre‑pay and post‑pay claim audits based on client, policy, industry standards and/or CMS guidelines. Job Details The Payment Integrity Analyst is responsible for accurately reviewing and completing pre‑pay and post‑pay claim audits based on client, policy, industry standards and/or CMS guidelines. Essential Functions & Responsibilities Reviews, analyzes, and completes internal audits and/or appeals in accordance with client policy, CMS guidelines and industry standards in clear and professional written communication. Use clinical judgement to appropriately interpret and apply client policies along with CMS guidelines as it relates to reviews done by CERIS such as itemized bill, DRG and/or specialty audits. Utilize applicable tools and resources to complete internal audits and/or appeals. Timely completion of internal audits and/or appeals. Attends clinical team meetings, company meetings, educational opportunities/trainings, and other meetings. Additional duties as assigned. Knowledge & Skills Ability to use clinical judgment and analytical skills for claim audit review. Knowledge of CMS/commercial payer policies, claims processing and reimbursements, ICD‑10 Coding, and DRG Validation. Familiarity with healthcare revenue cycle and coordination of benefits. Proficiency in Microsoft Office, especially using pivot tables in Excel as well as database tools. Excellent written and verbal communication skills. Strong interpersonal skills across all levels; comfortable interfacing with clients and the C‑Suite. Ability to work on several concurrent tasks and prioritize workload to meet designated deadlines. Advanced problem‑solving and data analysis capabilities. Proven track record of delivering actionable results. Strong attention to detail. Education & Experience Must maintain a current LPN, LVN and/or RN licensure. Previous experience in one or more of the following areas required: Medical bill auditing Experience in the acute clinical areas of facilities in O.R., I.C.U., C.C.U., E.R., Telemetry, Medical/Surgical, OB or L&D, Geriatrics and Orthopedics Knowledge of worker's compensation claims process Prospective, concurrent and retrospective utilization review 1+ years healthcare revenue cycle. 1+ years of relevant experience or equivalent combination of education and work experience. 1+ years hospital bill audit. Bachelor’s degree in healthcare or related field preferred. Preferred experience with health insurance denials and/or appeals, payer audits, or vendor audits. Pay Range CorVel uses a market‑based approach to pay and our salary ranges may vary depending on your location. Pay rates are established taking into account the following factors: federal, state, and local minimum wage requirements, the geographic location differential, job‑related skills, experience, qualifications, internal employee equity, and market conditions. Our ranges may be modified at any time. For leveled roles (I, II, III, Senior, Lead, etc.) new hires may be slotted into a different level, either up or down, based on assessment during interview process taking into consideration experience, qualifications, and overall fit for the role. The level may impact the salary range and these adjustments would be clarified during the offer process. Pay Range: $66,941 – $101,258. A list of our benefit offerings can be found on our CorVel website: CorVel Careers | Opportunities in Risk Management. In general, our opportunities will be posted for up to 1 year from date of posting, or until we have selected candidate(s) to fulfill the opening, whichever comes first. About Ceris CERIS, a division of CorVel Corporation, a certified Great Place to Work® Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities. We embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE‑IT!). A comprehensive benefits package is available for full‑time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre‑paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off. Equal Opportunity Statement CorVel is an Equal Opportunity Employer, drug‑free workplace, and complies with ADA regulations as applicable. #J-18808-Ljbffr CERIS