Analista de PLAFT at Financiera Oh! evaluating and managing financial crime risks. Assuring compliance with regulations and data analysis regarding high - risk clients.
About the role
- Claims Overpayment Analyst Lead responsible for analyzing and validating medical overpayments. Working to deliver measurable cost savings through expense recovery and cost avoidance.
Responsibilities
- Develops and executes complex data analysis
- Works with programming staff to ensure requirements will be incorporated into system design and testing
- Perform data mining utilizing CPT, HCPCS, DRG, ICD-9, ICD-10 to identify recovery opportunities
- Provides decision support and procedural input to ensure that processing efficiency does not compromise internal control mechanisms
- Validate overpayments, complete Approach document and forward necessary files and documents for CCU Load
- Documents and responds to any external audit requests
- Ensures proper conversion or shutdown of legacy systems by developing and documenting enterprise solutions for successful transition to core processing systems
- Research all resource documents and web-sites
- Submit enhancement request for database updates
Requirements
- Requires a BA/BS in accounting or finance
- Minimum of 5 years experience in a finance/health insurance field capacity
- Experience with relational databases and report writers
- Project management experience required
- Healthcare business analysis experience preferred
- Experience in using Facets, SQL and MACESS highly preferred
- Medical billing and/or claims processing experience preferred
- 2+ years of experience with data analysis, claims processing, provider billing, FWA investigations, cost containment, Medicare, Medicaid, MMP and/or MedSupp plans strongly preferred
- Medical coding experience - CPT, HCPCS, ICD-9/10 coding preferred
- CPC or applicable professional designation preferred
- Proficient in Microsoft Office products, especially Excel, Word, PowerPoint, Teams, and Outlook strongly preferred
- MBA, CPA, CMA, CFA or applicable professional designation preferred
Benefits
- Comprehensive benefits package
- Incentive and recognition programs
- Equity stock purchase
- 401k contribution
- Paid holidays
- Paid Time Off
- Medical, dental, vision benefits
- Short and long term disability benefits
- Wellness programs
- Financial education resources
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