Payment Auditor (Full-time Remote, North Carolina Based)

The Payment Auditor is responsible for ensuring that overpayments made by Alliance Health are recovered efficiently and that underpayments made by Alliance Health are promptly corrected. This is achieved through routine review of overpayments issued by Alliance Health and reported to Alliance Health as self-disclosures, and through routine review of potential underpayments identified through claims audits and payment demands submitted to Alliance Health.

This position is full-time remote. Selected candidate must reside in North Carolina. Some travel for onsite meetings to the Home office may be required.

Responsibilities & Duties

Provider Self-Disclosures

• Review provider self-disclosures to confirm accuracy, including review of claims, explanation of benefits, remittance advice
• Consult Program Integrity Analyst and Special Investigations Unit Supervisor to ensure that the self-disclosure can be accepted
• Coordinate claim adjustments with Claims Department
• Provide technical assistance to providers and billing representatives
• Request and review explanation of benefits
• Identify and report systemic issues that result in improper claims adjudication
• Track recoveries as required

Alliance Issued Overpayments

• Review claims that have been identified by Alliance Health as overpayments through audits/investigations to ensure proper adjustment and recovery
• Coordinate with Claims Department to identify and resolve barriers to recovery
• Consult with Program Integrity Analyst on overpayments subject to appeal, legal action, and settlement agreements
• Respond to provider inquiries about overpayment recoveries
• Track recoveries as required 

Data Analysis and Reporting

• Work with the Program Integrity Business Analyst and Information Technology staff to develop and update reporting capabilities
• Follows-up on notifications of audit findings issued by the Claims Audit Supervisor that include impact reports to ensure corrections have been implemented
• Complete quarterly overpayment recovery reports for internal committee review
• Complete annual overpayment recovery reports for Tailored Plan and Medicaid Direct

Underpayment Demands

• Receive and analyze underpayment demands from providers
• Consult with Claims Audit Supervisor and Claims Department to determine validity of the demands
• Communicate findings to Claims Research Analyst with pertinent recommendations
• Notify providers in writing of the final decision

Minimum Requirements

Education & Experience

Bachelor’s degree in a business-related field and at least three (3) years of experience in claims analysis and/or payment analysis and/or claim processing; or an equivalent combination of education and experience that provide the essential knowledge and abilities to perform the job.

Knowledge, Skills, & Abilities

• Strong working knowledge of ICD-10, CPT, and HCPCS coding principles, and standards.
• Ability to work independently and effectively manage projects, develop appropriate action plans to meet day-to-day responsibilities and demonstrate excellent verbal and written communication skills.
• Ability to interact with and educate internal and external customers.
• Detail oriented
• Ability to identify billing and processing issues
• Ability to identify and define potential and/or current issues of concern, collect and analyze data, establish facts, draw valid conclusions, and offer solutions.
• Working knowledge of coordination of benefits
• Ability to interpret explanation of benefits from variety of other payers
• Strong working knowledge of laws, regulations, policies and standards related to claims management and audits. 
• Ability to work independently and use sound judgment.
• Strong working knowledge of laws, regulations, policies and standards related to claims management and audits. 
• Knowledge of Medicaid