Additional Information
MISSION
Our mission is to enhance well-being by connecting individuals with vital health resources through a compassionate workforce that embodies the spirit of neighbors helping neighbors.
VALUES
HealthOne is guided by a cultural framework that embodies our values and drives our decisions.
Our PURPOSE is to care for people by connecting them to resources that help protect them in health related situations. To fulfill our purpose, we align our PRIORITIES to ensure each decision we make is ethical, empathetic, economical, and efficient. We care for PEOPLE by being welcoming, authentic, truthful, consistent, and humble. We are continuously looking for ways to improve our PROCESS and how we get things done.
HealthOne seeks individuals with integrity and heart to embody our values. Whether you're starting your career or looking to develop additional skills to reach your full potential, HealthOne provides the means to help you achieve your goals.
JOB PURPOSE
A Payment Integrity Analyst reviews healthcare claims, payments, and billing to find errors, fraud, waste, or abuse, ensuring compliance with rules (like CMS) and policies, using strong data analysis, medical coding (CPT/ICD-10), and auditing skills to prevent financial loss and improve accuracy, often working with vendors and internal teams. Key duties include auditing claims, investigating anomalies, analyzing data for trends, collaborating on billing edits, and preparing reports to support cost containment for health plans.
ESSENTIAL JOB DUTIES
- Review and audit healthcare claims to identify payment errors, overpayments, underpayments, fraud, waste, and abuse (FWA).
- Ensure compliance with CMS regulations, state and federal guidelines, health plan policies, and provider contract terms.
- Analyze medical records, itemized bills, and claim data to validate coding accuracy and medical necessity.
- Apply CPT, HCPCS, ICD-10-CM/PCS, and modifier guidelines to validate correct reimbursement.
- Identify trends, patterns, and anomalies through data analysis to support cost containment initiatives.
- Perform detailed reviews of high-dollar and complex claims to ensure payment accuracy, contract compliance, and medical necessity prior to or after payment.
- Investigate potential payment integrity issues, including duplicate payments, unbundling, upcoding, and incorrect modifiers.
- Collaborate with internal teams (Claims, Configuration, Provider Relations, Compliance, Legal, Analytics, Medical Management) to resolve findings.
- Work closely with internal and external vendors to review audit findings, validate recoveries, and implement corrective actions.
- Prepare detailed audit documentation, summaries, and reports for leadership, compliance, and recovery tracking.
- Present audit findings and recommendations to stakeholders in a clear and professional manner.
- Monitor and track audit outcomes, recoveries, and key performance indicators (KPIs).
- Participate in continuous process improvement initiatives to enhance payment accuracy and efficiency.
- Stay current with regulatory updates, coding changes, CMS guidance, and industry best practices.
- Support internal and external audits, regulatory requests, and compliance reviews as needed.
- Maintains regular and predictable attendance
- Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice
- Works to encourage and promote Company culture throughout the organization
- Other duties as may be assigned
Healthonellc · Dalton, GA