Senior Payment Accuracy Specialist (Pharmacy Data Mining)

Overview

Cotiviti Healthcare is a leading provider of payment accuracy services to the most recognized companies in the healthcare and retail industries. We are seeking innovative thinkers and creative problem solvers who are interested in making a contribution to improving healthcare and want to be part of a team that is expanding rapidly and providing opportunities for career growth. If you want to make a difference and contribute to the improvement of healthcare payment integrity, consider an opportunity to join our healthcare recovery team as a Senior Payment Accuracy Specialist.

The Senior Specialist position on our Pharmacy team is responsible for developing new and existing audit concepts, gaining client acceptance, training all audit levels to execute audit projects and evaluating the effectiveness of audit concepts. The goal of the position is to generate high quality recoverable claims for the benefit of Cotiviti and our clients. Conducts and documents more complex audit projects independently. This is the most senior skill level which may include supervisory responsibility. Assists Audit Managers in managing audit productivity, achieving expected quality and revenue goals. Considered a mentor, trainer, developer of less tenured Audit team members.

Responsibilities

• Generates and Develops New Audit Concepts. Utilizes healthcare and auditing experience to perform audit procedures that include identifying and defining issues, developing criteria, reviewing and analyzing evidence with the intent to audit standard medium and complex reports. Leader in concept development across multiple audit verticals. This includes specifying the concept, interact with client to test and gain acceptance. Will execute on the expansion of the concept based on customer requirements. Focused on growing concept approval.
• Develops New Tools and Processes. Collaborates with Business Optimization and audit team in developing new reports. Fosters and implements new ideas, approaches, and technological improvements to support and enhance audit production, communication and client satisfaction.
• Directs ownership for Quality Control. Reviews all level auditor claims prior to and after client submission. Set by the audit: for the auditing concept, audit against the expected level of quality and quantity (i.e.; hit rate, # claims written, ID per hour).
• Prepares Responses to Client Disputes. Provides oversight to audit team for verification of claims validation, insurance or employer validation in concise written or oral manner. Makes determinations based on advanced experience of client knowledge of contract terms, likelihood of acceptance recovery.
• Reviews provider Contracts. Subject matter expert in contracts and research requirements. Implements recommendations on contracts to fit projects within standard reports such as medical policies, state and federal statutes.
• Validates New Claim Types. With proficiency, utilizes audit tools to evaluate, document and validate to audit and client new claims and concept effectiveness. Ensures that any new and existing concepts are achieving desired goals in terms of recoveries, collectability and client acceptance.
• Auditor Development. Key participants in the development of audit staff. Actively trains audit team to execute basic, intermediate and complex audit projects with focus on new and existing audit concepts. May participate in auditor assessment, progression process, staffing functions.
• QA Claim Association/Concepts. Responsible for performing quality control process. Makes determinations based on advanced expertise and comprehension (knowledge) of claim categories, claim types. Ensures submission and execution of quality work, proper use of available proprietary software, reports and IT resources to conduct audits.

Qualifications

• Bachelor's degree preferred Three (3) years of Cotiviti direct audit experience OR four (4) years related experience (pharmaceutical billing, PBM audit processes, and Medical Pharmacy Payment Integrity, or analytics) required.
• Ideal candidates will showcase a nuanced understanding of how pharmaceutical claims are processed, adjudicated, and reimbursed within the healthcare ecosystem.
• Experience using Datameer and SQL preferred, as well as Pharmacy billing knowledge.
• Computer proficiency in Microsoft Excel, Access and system databases are required.
• Ability to mentor staff and enhance performance as it relates to the quality and productivity of their auditors.
• Prior Healthcare Billing and/or claims experience desired. Requires working knowledge of and applicable industry based standards including billing standards and practices concerning Drugs and Biologicals.
• Excellent verbal and written communication skills.
• Ability to work well in an individual and team environment.

Base compensation ranges from $36.50 to $39.00. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs. This role is eligible for discretionary bonus consideration.

Cotiviti offers team members a competitive benefits package to address a wide range of personal and family needs, including medical, dental, vision, disability, and life insurance coverage, 401(k) savings plans, paid family leave, 9 paid holidays per year, and 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti. For information about our benefits package, please refer to our Careers page.

Date of posting: 5/2/2024Applications are assessed on a rolling basis. We anticipate that the application window will close on 6/2/2024, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected.