You will report into the Manager, Payment Integrity (Pre-Pay).
Perform line-by-line review of high-dollar facility itemized bills and corresponding claim forms (e.g., UB-04s)
Compare billed charges against both payor-specific contracts and industry guidelines to confirm appropriate billing practices.
Apply working knowledge of national coding systems (e.g., CPT, HCPCS, ICD-10, MS-DRGs) to validate the accuracy of codes used for services billed.
Review claims eligible under specific reimbursement scenarios: a percentage of charges or those exceeding stop-loss levels, ensuring the claim exceeds the minimum dollar threshold set by the payor
Prepare clear, concise, and professional documentation of all findings, including savings identified, policy violations, and recommended claim adjustments
