AMVETS Jobs

Payment Accuracy Data Mining Specialist 1 Job Locations

US-Remote ID

2024-12528

Category Audit - Healthcare  

Position Type Full-Time Overview

A Payment Accuracy 1, Data Mining (DM) Specialist, is a member of the greater Data Mining Business Unit (BU). Cotiviti's Data Mining team configures custom claim reviews to investigate untapped billing compliance issues specific to regulations and contracted policies across product, market, and provider types. The Payment Accuracy 1, Data Mining (DM) Specialist is responsible for auditing client data and generating high quality recoverable claims for the benefit of Cotiviti and our clients.  Responsible for conducting or assisting in the identification, validation, and documentation of moderate to more complex audit projects.  Documents relevant facts, information, and conclusions drawn to support the work performed and validate the claim.  Utilizes this information to knowledge share within the audit team.  Displays a high degree of independent judgment and professional skepticism that enhances the work performed in order to achieve success in the position.

Responsibilities

This individual will work under direct supervision and will be monitored for efficiency in production and quality review of assigned work. * Has the ability to build and maintain a basic 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 and Duplicate Payment Reviews, Policy and Reimbursement Analysis, and Quality Assurance.  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, in addition to regular and predictable attendance, maintains production goals and standards set by the audit for the auditing concept. Achieves the expected level of quality and quantity for assigned work (i.e. 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 and Concept Expansion by researching and. .. For full info follow application link.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities