The Cost Containment Analyst reports directly to the Director of Claims Audit and Recovery. The Analyst monitors claims payment and refund trends, recovery/recoupment activity, provider billing behavior and system/benefit configuration updates. The Analyst will have a significant role in developing claims recovery tracking mechanisms, reports and processes. This role has the potential for high visibility, being a significant contributor in developing claims cost saving measurements.
* Provide in-depth analysis of claims payments to determine potential outliers or data trends. Identifies root cause issue and communicates findings to appropriate staff and make appropriate recommendations (increased monitoring etc.).
* Ensure all cases are properly documented for reference and review.
* Assists with managing relationship with recovery vendors and other partners.
* Communicate with Management regarding claims payment abnormalities and outcomes.
* Develop and recommend action plans for enhancing benefit outcomes while controlling costs.
* Work with internal staff to make them aware of potential overpayment abnormalities and develop a plan to rectify.
* Communicate with internal departments and providers regarding specific questions surrounding audits, procedures, and communications.
* Develop and maintain processes, tracking mechanisms, reporting and all relevant documentation used to take corrective actions.
* Work with Claims and Network Management to identify questionable behavior related to claims billing guidelines.
* Create and regularly review standard benchmarks for each market regarding claims payment.
* Coordinate targeted claim audits to ensure standards are met with contracted rates, benefit configurations and other claims processing guidelines.
* Utilize internal systems to generate information and analyze using system reports and write complex SQL queries.
* Contributing member for cross functional work teams tasked with identifying opportunities for system enhancements to more accurately process data in an efficient and adherent manner to program design. Subject matter expert on process improvement.
* Lead the industry in identifying new trends for monitoring and dealing with fraud, waste, and abuse.
* Bachelors Degree in related discipline preferred. High School Diploma and years of experience may be substituted for degree.
* 3 years of job related experience (data mining and claims/health care data analysis).
* Knowledge of claims processing systems (EZCAP preferred).
* Knowledge of medical terminology, standard coding and reference publications, CPT, HCPC, ICD-9, ICD-10, DRG, etc.
* Experience in processing/adjudicating medical, hospital and other facility claims.
* Proven problem solving skills and ability to translate knowledge to the department.
* Extensive experience and skills with Microsoft Office Products.
* Background in Medicare Advantage and/or Medical Group/IPA claims environment preferred.
* Excellent verbal and written communication skills.
* Ability to multitask.
* Strong Organizational Skills.
* Attention to Detail.
* Ability to use 10 key.
* Familiarity with CMS regulatory requirements.
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.