Be part of a team that unleashes the power of leading-edge technologies to help improve the health and well-being of those most vulnerable in our country and communities. Working at Gainwell carries its rewards. You'll have an incredible opportunity to grow your career in a company that values work flexibility, learning, and career development. You'll add to your technical credentials and certifications while enjoying a generous, flexible vacation policy and educational assistance. We also have comprehensive leadership and technical development academies to help build your skills and capabilities.
Summary
We are seeking a talented individual who serves as the SME in performing research analytics to support our recovery audit line of business. Primary focuses of the position includes identify new audit concepts, write specifications used to identify claims paid in error, audit paid claims data through multiple tools and methods, and perform quality assurance checks on existing concepts. In your role, you will assist in the development and implementation of new data mining opportunities and audit/review methodologies for identifying healthcare overpayments made to providers by insurance companies through data review and analytics. Provides guidance to lower-level analysts.
Your role in our mission Research client, State and Federal billing and reimbursement policies, client reimbursement practices (through review of manuals/regulations and meetings with stakeholders) to develop and configure improper payment algorithms. Results will need to be organized, documented, and trained to other team members. Reviews provider contracts to identify algorithms for the identification of contractual based overpayments. Performs scoping analysis and development of new overpayment algorithms. Applies knowledge of provider billing and patient accounting practices to research client policy and data to reveal new overpayment recovery opportunities. Works with other team members, clinical staff, and key stakeholders to identify new overpayment issues for each client. Participates in the review of health insurance claims and member eligibility information to uncover claims overpayment trends associated with non-compliance or misapplication of contract terms and rates, payment policies, medical policies, billing guidelines, and applicable regulatory requirements. Develops data extract specifications to select claims not paid in accordance with regulations for programming with trained engineers. Monitors internal systems used for tracking audits and findings to ensure high degree of accuracy and maximum productivity. Participate in query development process and reports query development progress and outcomes to leadership, internal and external clients, where necessary. Ensures individual and departmental goals are consistently met or exceeded, in collaboration with other team members and management. Reviews IT programming results for quality assurance and proof of concept validation. Documents results and supports preparation of internal and external documentation and presentations related to research and new overpayment issues. Works with internal operations and clinical teams to develop, implement, review and audit protocols and internal review guidelines. Uses advanced analytics to identify overpayment opportunities. Develops and validates workflows and communication tools to best enhance audit production, client satisfaction, and quality assurance. Works with data scientists and engineers to develop and implement technological improvements that will support the audit process. Contributes new ideas for improving existing audit processes and audit queries. Works cohesively with the entire audit team and internal clients. Acts as a team lead in assisting and guiding lower level analysts. Develops, maintains, and ensures adherence to multiple project schedules. What we're looking for 5-7 years healthcare reimbursement experience such as provider contract development, healthcare claims analysis, medical billing/coding, patient accounting, claims auditing, and/or revenue cycle improvement required. Experience in healthcare auditing, reviewing and validating the accuracy of claims data and accuracy of claims payment preferred. Experience applying published healthcare guidelines such as CMS regulations and coding guidelines to healthcare claims data, Recovery audit experience preferred. What you should expect in this role Fully Remote Opportunity Note
Video cameras must be used during all interviews, as well as during the initial week of orientation. The deadline to submit applications for this posting is 7/31/2024. The pay range for this position is $55,600.00 - $79,400.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You'll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.
We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You'll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our and visit our for all available job role openings.
Gainwell Technologies is committed to a diverse, equitable, and inclusive workplace. We are proud to be an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.
