Become a part of our caring community and help us put health first
 

The Senior Medical/Financial Risk Evaluation Professional is responsible for supporting the development, implementation and monitoring of medical/financial risk. The Senior Medical/Financial Risk Evaluation Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

The Senior Medical/Financial Risk Evaluation Professional identifies, assesses, and mitigates any medical or financial risk that arises from inadequate or failed processes, people, systems, or external events. Maintains a balance between risk mitigation and efficiency. Begins to influence department’s strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.

• Perform routine quality audits on PPI data mining partner concepts to determine payment accuracy, giving immediate feedback to assigned partner(s) as needed 

• Act as a liaison between internal areas and our PPI business partners 

• Lead business partner conference calls and meetings 

• Provide training when needed for PPI data mining business partners 

• Report/resolve security and system issues for external vendors 

• Monitor partner quality and provide ad hoc reports as needed 

• Identify data trends, develop solutions to improve processes, and assist with presenting and implementing recommendations and solutions 

• Lead or participate in cross-functional projects 

Use your skills to make an impact
 

Required Qualifications

• Minimum of 3 years of medical claims auditing experience (interpreting if claims initially paid correctly in the system) 

• Minimum of 2 years Provider Payment Integrity (formally known as Financial Recovery) experience 

• CAS claims knowledge 

• Prior vendor relationship experience/knowledge 

• Intermediate knowledge with Microsoft Excel and Power Point 

• Ability to confidently communicate verbally and via email with external vendor partners 

• Demonstrated strong emotional intelligence 

• Strong relationship building skills 

• Ability to self-start and prioritize on assignments given / research oriented 

• Experience with cross-functional project management, including summarization of project status, and presentation to leadership 

• Must be passionate about contributing to an organization focused on continuously improving consumer experiences 

Preferred Qualifications

• Bachelors Degree

• Knowledge of or the ability to gather knowledge on Medicare Advantage and Medicaid State Regulations 

• Certified Professional Coding (AAPC) 

• Previous experience working with the internal PPI peer teams (Code Edit, Prepay, CCRO, Missed Opportunities, etc.) 

• Experience with provider contracts, understanding intent and possible load issues for claims payment impact 

Additional Information

As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experie