Excellus Health Plan Inc.
Utica, NY, USA
Job Description: Summary: This position is responsible for the accurate and thorough claim and clinical investigation of potential claim payment integrity issues involving all lines of business. This position investigates and remediates claim overpayments, creating data and reporting analytics to analyze data from multiple sources to extract trends, business insights, and to ensure claims payment integrity. Activities are performed through a variety of audits utilizing various systems, data applications, and/or medical records and directed toward reducing costs for the Health Plan, identifying risks and trends, facilitating, and collaborating with stakeholders from all business units on root cause analysis to implement solutions compliant with Provider/Member contracts, as well as internal/external standards set by regulatory and accreditation entities. Essential Accountabilities: Level I Adherence to official coding guidelines, coding clinic determinations, and CMS and...