Insurance Payment Variance Analyst

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Summary

The Insurance Payment Variance Analsyt performs day-to-day payment variance activities within the Hospital and/or Medical Group revenue operations for South Shore Health. The scope of responsibility will be resolution of all open claim payment variances (overpayments and underpayments) for 20 insurance payors loaded into Experian. Additionally, this role researches the root cause of variances and utilizes historical data to provide detailed analytical summaries for South Shore leaders. Serves as part of the Payment Variance team responsible for ensuring proper claims payments are received from insurance companies, determining root causes for discrepancies, minimizing inappropriate payment delays and variances from expected reimbursement, and resolving or escalating issues to the Manager for resolution. This is a hybrid position and reports directly to the Supervisor.

ESSENTIAL FUNCTIONS

Investigates and addresses overpayment and underpayment accounts with the objective of appropriately optimizing reimbursement for services rendered. Ensures that claims are paid/settled in the timeliest manner possible:

1. Strategically applies knowledge of specific payer payment rules, managed care contracts, reimbursement schedules, eligible provider information and other available data and resources in order to research payment delays and variances, make corrections, and take appropriate corrective action to ensure timely claim resolution. ]

2. Proactively follows up on payment delays and variances by contacting patients and third-party payers, and supplying additional data, as required.

3. Conducts ongoing analysis of contract compliance and financial performance for third-party payers to provide leadership with support during payer contract negotiations

a. Supports payer strategy teams by reviewing and comparing regular contract/rate adjustments provided by payers

b. Researches and provides data independently for recommendations used in payer negotiation processes

4. Reports and maintains data on types of variances and root cause. Collaborates with management and team to make recommendations for improvements.

a. Analyzes and researches historical data loaded into Experian to trend and identify ongoing issues for specific payors or plans

b. Samples aged variance accounts within Epic to identify root cause, carrying forward that knowledge for future recommendations

c. Utilizes data files to create visualizations to support the variance coordinator in meetings with South Shore Revenue Cycle leadership

5. Develops analytical performance dashboards with key performance indicators, formulas, and other reimbursement related data to track historical reimbursement trends

6. Acts as the designated liaison for payers, as well as for other internal departments and leadership, regarding payment accuracy

7. Composes adjusted claims and appeal letters to resolve payment rejections.

8. Requests write offs, transfers, allowances, and reversals.

9. Documents all actions and encounters in the patient accounting system using standard codes. 10. Maintains working knowledge of the areas of third-party billing, reimbursement schedules and methodologies, coding, payer contracts, billing and payment rules and regulations, and hospital billing compliance

11. Actively participates in recurring trend research meetings with HB and PB Billing and Follow up teams, providing analytical insights from research conducted in the role

Technology and Learning

a - Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.

b - Embraces technological advances that allow us to communicate information effectively and efficiently based on role.

JOB REQUIREMENTS

Minimum Education - Preferred

Bachelor's degree in Accounting or Business Administration or related field

Minimum Work Experience

Minimum of 5-10 years' of experience and relevant knowledge of revenue cycle functions and systems working within a hospital or clinic environment, a health insurance company, managed care organization or other health care financial service setting, performing medical claims processing, financial counseling, financial clearance, accounting or customer service activities or an equivalent combination of education and experience.

Required additional Knowledge, and Abilities

Excellent written and verbal communication skills and organizational abilities.

Strong interpersonal skills in interacting with internal and external customers.

Strong accuracy, attention to detail and time management skills.

Advanced understanding of Microsoft Office, including Outlook, Word, PowerPoint, and Excel.

Research and analytically oriented in work and analyses completed

Epic and/or Experian experience preferred but not required.

Detailed knowledge of reimbursement schemes for predominant payors.

Detailed knowledge of CPT-4, HCPCS, revenue codes and ICD-10 CM.

Completion of regulatory/mandatory certifications and skills validation competencies preferred.

Must be comfortable operating in a collaborative, shared leadership environment.