Payment Integrity Specialist

Summary
The Payment Integrity Specialist position is focused on the processing of provider Medicare and Commercial claims disputes. This associate will review incoming complaints and determine the appropriate response based on the provider’s contract and configuration in our system as well as the subscriber’s benefit plan.
The Payment Integrity Specialist will interact daily with the Claims, Customer Service Department, Medical Management, providers, and Provider Relations staff as may be necessary to effectively resolve disputes. This role is also responsible for various quality assurance activities, including auditing and monitoring activities of the processed cases and correspondence.
Reports to: Manager, Payment Integrity
Location: Houston, TX; will consider remote deployment on a case-by-case basis
Essential Functions

• Interact with internal departments, such as Customer Service, Medical Management, Configuration, Contracting, Claims and Provider Relations, as well as providers and other external entities to effectively process provider disputes in a timely and appropriate manner
• Investigate provider disputes to find root cause of complaint
• Communicate decisions with appropriate, understandable correspondence
• Work directly with Manager to meeting the department needs
• Other Ad Hoc Payment Integrity departmental functions

CANDIDATE QUALIFICATIONS

• Bachelor’s or associates degree in related field; in lieu of a degree, a high school diploma and five years in a managed care environment performing in appeals review/investigation function will be considered
• License/certification: None
• Five years of health insurance/managed care experience
• Knowledge of healthcare terminology preferable
• Strong written and verbal communication skills
• PC proficiency to include Microsoft office products
• Some travel in the Houston metro area may be required
• Remote deployment will be considered