RCM Payer Reimbursement Integrity Specialist

Job Description

Job Description

Position Summary / Scope of Responsibility:

MedVanta is the nation's largest physician-owned and operated next generation management services organization (MSO). Our services are specifically designed for musculoskeletal (MSK) providers and go beyond that of a traditional MSO, empowering our clients with the precise infrastructure, data, technology, and administrative processes needed to thrive both today and tomorrow.

MedVanta has an employee centered culture that supports and promotes diversity and inclusion. Our encouraging and empowering management style makes MedVanta a great place to further grow your knowledge while building a team driven path to success.

The RCM Payer Reimbursement Integrity Specialist is responsible for ensuring that all payer reimbursements are accurate and compliant with contract terms, federal and state regulations, and healthcare policies. This role involves extensive analysis of payer contracts, reimbursement calculations, audits, and data management to identify discrepancies, underpayments, and opportunities for revenue optimization.

Primary Responsibilities:

The incumbent may be asked to perform job-related tasks other than those specifically stated in this description. The duties and responsibilities of the position are to be carried out in a manner that is consistent with the Mission, Core Values and Operating Principles of MedVanta.

• Subject Matter expert in reviewing Fee Schedules, Payer contracts, and related Master Charge agreements.
• Advanced knowledge in analyzing and creating abstracts of all Payer Contracts to ensure fee schedules and related terms are updated.
• Maintains and updates spreadsheets, databases, and systems as a guide for tracking fee schedules and Payer Contract terms.
• Keep track of all payer contract changes during the year to update abstracts and fee schedules accordingly.
• Scrubs claims in the back-end, once they have been paid off and/or fully denied (past normal denial and/or appeal process) to ensure it was accurately paid based on the applicable fee schedule.
• Conducts comprehensive audits of payer reimbursements to ensure compliance with contract terms and rates.
• Analyzes complex reimbursement methodologies and rate structures, including fee-for-service, bundled payments, capitation, and others.
• Collaborates with billing and coding departments to ensure accurate charge capture and submission based on payer contract specifications.
• Develops and implements strategies for maximizing reimbursements and reducing denials through data-driven analysis and payer negotiations.
• Prepares detailed reports and analyses for management, highlight trends, issues, and opportunities in payer reimbursements.
• Advanced capabilities in oral and written presentations to leadership and Physicians.
• Maintains updated knowledge of changes in healthcare regulations, payer policies, and industry trends affecting reimbursement rates and methodologies.
• Educates and trains staff on fee schedules, payer contracts, reimbursement processes, and compliance requirements.
• Ensures strict confidentiality and compliance with HIPAA regulations and all applicable healthcare laws and policies.
• Partners with the Sr VP of Managed Care Contracting and Payer Strategies to obtain updated payer contract information and maintain fee schedules.
• Performs other duties as assigned.

Required Education and Experience:

1. High school diploma required. Bachelor's degree preferred.

2. 3+ years’ experience working in a medical billing office required.

3. Advanced skills in Microsoft Office suite applications, EMRs, and payer websites.

4. 3+ years’ experience with payer contracts and auditing payer payments.

5. 3+ years’ experience using contract management software.

6. Proven understanding of healthcare reimbursement methodologies, payer contracts, and state/federal regulations.

7. Experience successfully collaborating across multiple functional areas and departments.

8. Experience successfully innovating in a fast-growing work environment while dealing with ambiguity as a self-starter with integrity and a driven work ethic.

Competencies / Required Skills and Abilities:

1. Heavily analytical mind with an acuity for investigation and repair.

2. Strong Interpersonal, oral, and written communication skills with excellent self-discipline and patience.

3. Confident, independent thinker and strong decision-making ability when circumstances warrant such action.

4. Demonstrated ability to organize, prioritize, and manage multiple tasks in a dynamic environment with a proven track record of results.

5. Ability to develop relationships and collaborate in a decentralized organization. Able to work independently as well.

6. Exudes professionalism in presentation.

7. Must be able to read, write, speak, understand, and communicate in the English language.

Physical Demands:

1. Must be able to sit for long periods of time and lift up to 25 pounds.

2. Must be able to use appropriate body mechanics techniques when performing desk duties.

3. Requires frequent bending, reaching, repetitive hand movements, standing, walking, squatting, and sitting.

4. Adequate hearing to perform duties in person and over telephone.

5. Must be able to communicate clearly to patients in person and over the telephone.

6. Visual acuity adequate to perform job duties, including reading materials from printed sources and computer screens.