[Hiring] Payment Integrity Representative @Sanford Health

Role Description

Responsible for reviewing, maintaining, and analyzing underpayment records and managed care contracts to ensure Sanford is paid according to contract terms for system billing, maximizing reimbursement, and maintaining compliant practices.

• Develop, document, and oversee standard operating procedures in One Note to ensure consistency in business rules applied in claim adjudication.
• Possess in-depth understanding of reimbursement techniques and strategies.
• Knowledge in reimbursement/payment classification systems, fee schedules, and managed care contracts.
• Knowledge of Remark and Reason codes sent from payors as well as reading a remittance advice.
• Responsible for the appeals related to underpayments & overpayments according to Sanford's internal guidelines.
• Work with reimbursement analysis and testing by payor, analyze trending of managed care issues by payor, and assist in reviewing managed care activity in the system.
• Able to interpret and analyze complex managed care contracts and schedules to ensure payments received as contracted.
• Ability to analyze information objectively and draw a rational conclusion.
• Complete extensive research to determine if claims are being paid correctly per separate guidelines that payors have that are not part of Sanford contracts.
• Lift up payment processing policies that are being deployed by the payors to Sanford Contracting team.
• Identify errors by operational departments, research and provide guidance on how coverage should be set up.
• Identify and communicate enrollment issues when new payors are brought on.
• Identify systemic issues with payor claim systems by investigating and finding patterns of claim variances.
• Facilitate education and distribution of relevant information to internal departments and payors.
• Ability to call payors to help identify the issue on a particular underpayment, being able to collate well for final resolution.
• Support billing and finance in developing and conducting analysis and reporting to aid operational decision making.
• Committed to working in a fast-paced, high-volume, and changing environment and have a high energy level and the ability to accomplish objectives.
• Cultivate positive working relationships with management, staff, and other departments.
• Skilled in negotiation, able to build consensus while managing the delicate managed care relationships between system and payors.

Qualifications

• Associate degree in healthcare or business related field required or in lieu of education will accept a minimum of three years prior healthcare revenue cycle experience.
• Experience working with Excel spreadsheets required.
• Minimum two years prior healthcare experience with an understanding of healthcare reimbursement preferred.

Requirements

• Must meet standard productivity requirements prior to moving to a home-based position; if meeting productivity requirements but with less than one year working in Sanford office, must have Director approval to move to a home-based position.

Company Description

Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland.