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Payment Validation Analyst


Department Description: The Contract Payment Systems & Payment Validation Department is responsible for all aspects of the contract payment systems through data analysis, managing vendor relations and maintenance of applications. Additionally, the department is accountable for the validation of payments for our community hospitals by making sure that services provided are reimbursed according to the contractual agreements with all payers.

Job Location: Boston, MA

Req ID: 30211BR


Job Summary: Under the direction of the Manager of Contract Payment Systems and Payment Validation, the Payment Validation Analyst evaluates unresolved third party claims issues due to billing processing errors, coding edits, rejections, denials, and payment variances for multiple hospitals within Beth Israel Deaconess Medical Center. In addition, this position provides support to Patient Financial Services, Audit and Underpayment Teams for accounts resolution.

Essential Responsibilities:
  1. Performs data analysis on claim payments, and troubleshoots discrepancies and claims denials. Responsible for researching claims using the hospitals' payment and billing systems.
  2. Follows-up with insurance companies to resolve appeals, and discrepancies in payment within standard billing cycle.
  3. Utilizes payer portal websites for payment policies and procedures to validate payment. Reviews payment variances using Harvest system to identify underpayment opportunities for all payers effectively.
  4. Works on rebill projects that are focused on the recoupment of underpayments pertaining to medical coding, payer edits, or missing key elements on the claims.
  5. Responsible for updating payment system with rate changes, and performing data validation. Reviews underpayments and variances for accuracy and completeness in a timely manner.
Required Qualifications:
  1. High School diploma or GED required. Bachelor's degree preferred.
  2. 3-5 years related work experience required.
  3. Experience in a medical billing office or health insurance industry claims related setting. Familiar with CPT, HCPS and ICD-10, Medical Coding.
  4. Effective communication abilities for phone contacts with insurance payers to resolve issues.
  5. Attention to detail and experience with the electronic and paper systems used in medical billing.
  6. Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint or Access and other web-based applications. May produce complex documents, perform analysis and maintain databases.
Preferred Qualifications:
  1. Knowledge of insurance guidelines including HMO/PPO, Medicare and Medicaid and other payer requirements and systems.
  2. Health insurance billing and coding, receivables management, collection and data processing interface experience.
Competencies:
  1. Decision Making: Ability to make decisions that are guided by general instructions and practices requiring some interpretation. May make recommendations for solving problems of moderate complexity and importance.
  2. Problem Solving: Ability to address problems that are varied, requiring analysis or interpretation of the situation using direct observation, knowledge and skills based on general precedents.
  3. Independence of Action: Ability to follow precedents and procedures. May set priorities and organize work within general guidelines. Seeks assistance when confronted with difficult and/or unpredictable situations. Work progress is monitored by supervisor/manager.
  4. Written Communications: Ability to communicate clearly and effectively in written English with internal and external customers.
  5. Oral Communications: Ability to comprehend and converse in English to communicate effectively with medical center staff, patients, families and external customers.
  6. Knowledge: Ability to demonstrate full working knowledge of standard concepts, practices, procedures and policies with the ability to use them in varied situations.
  7. Team Work: Ability to interact respectfully with other employees, professional staff and/or external contacts to offer ideas, identify issues, obtain information or deliver services.
  8. Customer Service: Ability to provide a high level of customer service to patients, visitors, staff and external customers in a professional, service-oriented, respectful manner using skills in active listening and problem solving. Ability to remain calm in stressful situations.

Physical Nature of the Job:
Sedentary work: Exerting up to 10 pounds of force occasionally in carrying, lifting, pushing, pulling objects. Sitting most of the time, with walking and standing required only occasionally

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