Policy And Payment Integrity Team Lead

The Payment Integrity Team Lead assists with leading the Policy and Payment Integrity (PPI) team in a fast paced setting while maintaining their own duties and responsibilities. In this position, you will be managing members of the PPI team including developing team strengths and improving weaknesses, identifying team goals, and evaluating team progress.
The Team Lead must be knowledgeable of the application of client Policy and industry standards within reviews conducted by CERiS including but not limited to itemized bill review, professional review, hospital outpatient and DRG validation; trend analysis of internal auditing of claims for claim accuracy related to pre and post payment claims, targeted claims, high dollar claims, and any other claim or record that requires quality review to determine the claim accuracy; assist with development of internal quality assurance measures based on client Policy and industry guidelines; perform quality assurance reviews (as needed); assist in researching and implementing best practices related to payment policy, and/or policy initiatives; researching various healthcare policies; interpreting client, state, and CMS payment policies; assist in writing internal quality assurance policies; work with department managers in implementing payment policies and processes to meet quality assurance guidelines.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:
• Assists with staff communication, providing updates, resolving issues, setting goals and maintaining standards.
• Oversees team member work for quality and compliance
• Communicates deadlines and productivity goals to team members
• Dialogue with team members in efforts to answer their questions and resolve barriers
• Provides ongoing training and education to staff to ensure policies and procedures are followed
• Verifies and corrects as necessary, the audit work completed by PPI QC analysts and clinical appeal review teams as needed
• Exercises good judgment to resolve complex claim and appeal issues in the absence of detailed instructions or in an emergency situation
• Motivates the team to achieve organizational goals
• Research, interpret and apply CMS, Federal, State and client policies to claims review
• Demonstrate ability to manage multiple projects, set priorities and manage to committed schedule
• Strong interpersonal skills and adaptive communication style, complex problem solving skills, drive for results, innovative
• Act as a resource and liaison for internal departments, account management, senior management and clients as needed
• Additional duties as assigned.

KNOWLEDGE & SKILLS:
• Strong knowledge of itemized bill review, ASC and outpatient claim review
• Ability to demonstrate understanding of CMS and commercial payer policy in written and verbal format
• Strong understanding of claims processing, ICD-10 Coding, DRG Validation, Coordination of Benefits
• Strong understanding of healthcare revenue cycle and claims reimbursement
• Proficient in Microsoft Office including Pivot Tables and Database Management
• Comfortable interfacing with clients and the C-Suite
• Demonstrate ability to manage multiple projects, set priorities and manage to committed schedule
• Strong interpersonal skills and adaptive communication style, complex problem solving skills, drive for results, innovative
• Excellent written and verbal communication skills
• Proven track record of delivering concrete results in strategic projects/programs
• Strong analytical and modeling ability and distilling data into actionable results
• Superb attention to detail and ability to deliver results in a fast paced and dynamic environment

EDUCATION/EXPERIENCE:
• Must maintain a current RN licensure in the state of employment
• Minimum of 5 years’ experience in Operating Room, either as a circulating RN or scrub RN, as well as 2 years’ clinical experience in an acute care facility
• Previous experience in the following areas preferred:
o Medical bill coding and auditing
o 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
o Knowledge of worker's compensation claims process
o Prospective, concurrent and retrospective utilization review
• Bachelor’s degree in healthcare or related field
• 5+ years of relevant experience or equivalent combination of education and work experience
• 3+ years hospital bill audit
• 1+ year project management

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.

CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.