Develops and executes complex data analysis
Works with programming staff to ensure requirements will be incorporated into system design and testing
Perform data mining utilizing CPT, HCPCS, DRG, ICD-9, ICD-10 to identify recovery opportunities
Provides decision support and procedural input to ensure that processing efficiency does not compromise internal control mechanisms
Validate overpayments, complete Approach document and forward necessary files and documents for CCU Load
Documents and responds to any external audit requests
Ensures proper conversion or shutdown of legacy systems by developing and documenting enterprise solutions for successful transition to core processing systems
Research all resource documents and web-sites
Submit enhancement request for database updates

Requires a BA/BS in accounting or finance
Minimum of 5 years experience in a finance/health insurance field capacity
Experience with relational databases and report writers
Project management experience required
Healthcare business analysis experience preferred
Experience in using Facets, SQL and MACESS highly preferred
Medical billing and/or claims processing experience preferred
2+ years of experience with data analysis, claims processing, provider billing, FWA investigations, cost containment, Medicare, Medicaid, MMP and/or MedSupp plans strongly preferred
Medical coding experience
CPT, HCPCS, ICD-9/10 coding preferred
CPC or applicable professional designation preferred
Proficient in Microsoft Office products, especially Excel, Word, PowerPoint, Teams, and Outlook strongly preferred
MBA, CPA, CMA, CFA or applicable professional designation preferred

Claims Overpayment Analyst – Lead

Key skills