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Payment Integrity Coordinator - Health Alliance Plan

Company: Health Alliance Plan of Michigan
Location: Troy
Posted on: September 9, 2020

Job Description:

GENERAL SUMMARY:

Responsible for first level audit activity including researching claims, contracts, HAP guidelines, and national coding standards. Responsible for the day-to-day activities working with vendors including assisting identifying correct pricing, contract language related to audit and payment, as well as responsible for vendors commission payments. Works closely with Payment Integrity auditors on more cases that are complex where assistance is needed.

PRINCIPLE DUTIES AND RESPONSIBILITIES:



  • Coordinate Payment Integrity audit mailings and verify all responses have been received and information is complete.
  • Initiates follow-up letters for audits if needed due to lack of response or missing information, initiates call if needed, to follow-up on record requests.
  • Conduct outreach to obtain needed information such as medical records, refunds of overpayments or other information to support FWA audit activity. Initiate Payment Integrity audit files.
  • Collect, record, and input required data elements using standardized formats designed to track Payment Integrity projects.
  • Assist Payment Integrity Auditors with research that may include reviewing Facet membership, claim information and web searches.
  • Pull and copy provider and employer group contracts as needed.
  • Monitor the timely submission of overpayment refunds and corrective action plans including notifying Payment Integrity auditor if due date is not met. Ensure that the corrective action plans include the necessary information to address the problem identified.
  • Responsible for reviewing vendor commission requests, preparing check request and facilitating claim adjustment and recovery letters as needed.
  • Pull standard reports as directed.
  • Perform other related duties as assigned.
  • Contact providers as needed to explain audit or investigation results including but not limited to explaining fraud, waste, and abuse edits and why a claim was denied.
  • Coordinate second and third level appeals.


    EDUCATION/EXPERIENCE REQUIRED:



    • Bachelor's Degree in health administration or equivalent preferred.
    • Minimum of five (5) years of experience in health related business. This may include working in provider (i.e., hospital, physician, ancillary) or payer setting (i.e., claims, customer service, grievance, operations) or related coordinator experience (i.e., process management).
    • Experience related to payment methodologies (i.e., DRG, APC, percent of charge, per diem) preferred.
    • Strong interest in coding and auditing preferred.
    • Strong interest in obtaining coding certification preferred.








Keywords: Health Alliance Plan of Michigan, Troy , Payment Integrity Coordinator - Health Alliance Plan, Healthcare , Troy, Michigan

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