Payment Accuracy Specialist 1

• This individual will receive direct supervision and ongoing support to ensure efficiency in production and quality review of assigned work.
• Demonstrates the ability to build and maintain a solid understanding of Centers for Medicare and Medicaid Services (CMS) and National Association of Insurance Commissioners (NAIC) guidelines to establish the correct order of liability.
• Proficient with Cotiviti audit tools Recovery Management System (RMS), specific client systems) to complete auditing, review simple - medium proprietary reports, has an advanced understanding of Microsoft Excel and client applications.
• Draws on prior experience to audit standard reports and paid claims to identify over and under-payments of claims. The scope may include Data Mining, Claim Adjudication, Contract Compliance, Provider Billing & Duplicate Payment Reviews, Policy & Reimbursement Analysis, and Quality Assurance. This role is assigned to medium/complex reports.
• Enters overpayments into Cotiviti system accurately and in accordance with standard procedures. Identifies and discusses audit findings with the audit team as a part of knowledge sharing and concept expansion.
• May update current reports, develop, and run custom queries and validate the accuracy of current reports used. Makes determinations based on prior knowledge and experience of client contract terms with the likelihood of recovery acceptance.
• Meets or exceeds standards for productivity, maintains regular and predictable attendance, and achieves production goals and standards set by the audit for the auditing concept. Ensures the expected level of quality and quantity for assigned work, including hit rate, claims written, vendor/project volume completion, ID, and/or fees per hour.
• Meets or Exceeds Standards for Quality by achieving the expected level of quality set by the audit for the auditing concept, for valid claim identification and documentation.
• Responds effectively to inquiries received on claims written. Provides verification of claims validation and confirmation, in a concise written manner, utilizing facts and details for justification purposes.
• Demonstrates aptitude in reviewing transaction types, client contracts/vendor agreements, and client data with limited supervision of how to identify potential over or underpayments. Makes recommendations on medical policy application, state and federal statues, and other reimbursement methodologies as it applies to the audit concept.
• Participates in onboarding new hires and cross-training efforts.
• Identifies New Claim Types & Concept Expansion by researching and identifying potential claims outside the audit concept. Suggests, develops, and analyzes high quality, high value concepts and/or process improvements, tool enhancements, etc.
• Recommends New Concepts & Processes by leveraging knowledge of client, contract terms, and complex claim types. Works towards developing and implementing new ideas, approaches, and/or technological improvements that will support and enhance audit production. Evaluates information and draws logical conclusions. Uses learned, tried, and proven validation methods to test and produce the desired/intended result of the new concept. May collaborate with Engineering in the development of new reports.
• Demonstrates understanding of Cotiviti policies & procedures, and external regulatory requirements and performs duties in accordance with such regulatory requirements.
• Ensures confidentiality and security of all data, adhering to all HIPAA (Health Insurance Portability and Accountability) laws and requirements. Demonstrates the skills, knowledge, and ability to ensure that our environment is safe, complying with industry standards.

This job description is intended to describe the general nature and level of work being performed and is not to be construed as an exhaustive list of responsibilities, duties and skills required. This job description does not constitute an employment agreement and is subject to change as the needs of Cotiviti and requirements of the job change.