Identification of overpaid claims by:
Identifying / analyzing / validating claim over-payments related to eligibility and contract terms
Validating and recovering of over-payments via communication with providers and health insurance plans (both written and verbal)
Maintaining compliance with state claim recovery rules and regulations
Maintaining recovery files with accurate and current information and documentation
Exceeding monthly production over-payment identification and recovery goals while maintaining excellent accuracy levels
Perform Quality Assurance against production inventory by:
Reviewing specific proportions of claims written by auditor, client, LOB, provider, etc
Communicating errors back to claim authors and providing additional education where needed
Create recoverable inventory by:
Auditing already-established reports based on existing content
Training/mentoring production auditors to work each concept
Performing ad hoc reviews/projects given to us by clients, or other teams
The ideal candidate for the Data Mining Analyst opportunity will be an innovative, independent self-starter with interest in Quality Assurance and Mentoring new employees. Top talent will also possess thorough knowledge of the healthcare reimbursement space. Requirements are as follows:
3+ years of directly relevant experience and/or training in both data analysis and healthcare reimbursement.
Knowledge of medical and/or pharmacy coding, billing and reimbursement methodologies, e.g. CPT/HCPCS, ICD-9/10, DRG (MS, AP, APR), APC, Modifiers, Natl. Correct Coding Initiative, etc. Professional certifications, such as Certified Professional Coder (CPC), Certified Coding Specialist (CCS), etc. are a plus.
Proficiency in query-based extraction and examination of data, including basic SQL knowledge and/or expert knowledge of Microsoft Excel.
A thorough understanding of health plan adjudication systems and the claims life cycle, i.e. reimbursement logic and its connection to the paid claims data supplied by the health plan for audit. This includes knowledge of facility and professional contracting and its relationship to the adjudication process, prior authorization, utilization management, medical policy, etc.
Strong mentoring/training skills to facilitate the movement of discovered content into the production cycle by develop and supporting less experienced team members.
A bachelor's degree in a quantitative (finance, statistics, etc.), or healthcare-related field (preferred, not required).
Excellent verbal and written communication skills, with strict attention to detail and accuracy.
An independent, figure-it-out, do-it-yourself approach.
Polished interpersonal skills, both within the company and client-facing.
Outstanding organization and prioritization skills, with a strong sense of urgency.
A highly curious attitude with a passion to create/innovate.
The ability to adapt and thrive in a fast-paced, constantly changing environment.
The position is based out of the Equian office in Louisville KY, but consideration will be given to candidates outside of this location.