Sr. Provider Audit Analyst

Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. 

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health.

Job Summary

The Provider Audit Analyst audits claims for coding accuracy, benefit, payment and contract interpretation in accordance to claims processing guidelines, HPHC Medical and Payment Policies and established audit protocol. He/she handles complex issues requiring extensive knowledge of claim systems, claims analysis, policies, quality assurance and appeals review process to accurately assess current and historical performance and identify opportunities for improvements in reimbursement policy, medical policy, quality, operations, and/or utilization.

Job Description

Key Responsibilities/Duties – what you will be doing (top five):

• Accountable for the overall quality and accuracy of assigned individual audits as well as the accompanying data mining, analytics, and summary reporting.
• Typically manage $.5M to 1M each in recoveries/year. Utilize comprehensive knowledge of CPT, HCPCS, ICD10-CM diagnosis and procedure codes to assist in claims data analysis related to policies and recovery identification.
• Coordinates findings and recoveries with multiple departments across the organization including but not limited to: Contracting, Claims, SIU, and Finance.
• Responsible for all aspects of project analysis from: conceptualization, development of queries, programming, execution, problem identification, and resolution, recovery, reporting and recommendations.
• Integrates data from multiple internal and external resources to develop and present recommendations for recoveries to management.
• Other duties and projects as assigned.

Qualifications – what you need to perform the job

Certification and Licensure

• Coding Certification (CPC, CCS or equivalent); Maintenance of credential status.

Education, Certification and Licensure

• Required (minimum): Bachelor’s degree in a related field
• Preferred: Master’s degree

Experience (minimum years required):

• Required (minimum): 5-7 years of related professional healthcare experience including familiarity with medical claims processing.
• Preferred: 8-10 years of related work experience

Skill Requirements

• Excellent analytic, critical thinking and organizational skills, including knowledge of analytic and statistical concepts, techniques, and methods.
• Proven ability to function independently and creatively.
• Proven analytic experience and skilled at manipulating, analyzing, and evaluating large data sets at various levels of detail; knowledge of SAS or other programming language (SQL) and advanced use of MS Access and Excel.

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Salary Range

$80,607.48 -$120,911.22

Compensation & Total Rewards Overview

The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization.  The actual salary for this position will be dete