Consultant, Payment Intelligence chicago, il

Consultant, Payment Intelligence chicago, il

 
The Role

Health plans face continued challenges in reimbursing claims on-time and accurately.   consulting service line, Payment Intelligence®, goes beyond typical payment integrity to ensure erroneous and inefficient payments are identified, rectified, and recouped to prevent them in the future. Our Payment Intelligence® team addresses issues with payment policies, provider contracts, provider data, covered benefits, member eligibility and prior authorizations.

In this role, the individual will be responsible for client delivery of Payment Intelligence® . The position will report to a Payment Intelligence® Manager. The individual will be the subject matter expert on strategies to help our clients ensure proper claims payment through the use of (1) claims analytics, (2) process improvements, (3) integration of automation/technology, and (4) configurations setups. This role will also support the internal development of Payment Intelligence initiatives.

Work You’ll Do

Support the development, identification and analysis of payment accuracy opportunities through remediation with client counterparts
Utilize analytics to identify claims payment opportunities through your knowledge of standard payment methodologies including Prospective Payment Systems (IPPS/OPPS), fee for service, Groupers, RUG, etc.
Support process improvements and automation initiatives for clients
Conduct research on current events, changes in regulatory requirements and market trends impacting health plan reimbursement
Contribute to the preparation of client ready deliverables with clear and actionable insight
Exercise sound judgement and clear and direct communication in all aspects of your work
Other duties as assigned

Requirements

2+ years of experience in a role within consulting, provider revenue cycle, a payment integrity vendor, and/or a payer organization
Foundational knowledge of claims processing across multiple lines of business, including Medicare, Medicaid, ACA/Marketplace, Commercial, and Duals
Experience across various spend areas, including professional, ancillary, outpatient, and inpatient services
Ability to identify and analyze mispaid claims to ensure accuracy and compliance
Knowledge of industry vendors and tools related to claims processing, provider data, and contract management
Understanding of end-to-end claims processes, including claims management, provider lifecycle, and network optimization
Strong professional communication skills, including written, verbal, interpersonal, and in-person presentation expertise
Experience coaching and mentoring team members
Advanced proficiency utilizing Microsoft Excel and basic/intermediate SQL for data analysis
Strong analytical, data interpretation, and problem-solving skills
Ability to identify client savings opportunities and develop actionable business cases
Bachelor’s degree or equivalent
Direct client interaction with possible travel to client locations 
Must be legally authorized to work in the United States without the need for employer sponsorship
Preferred Requirements

Policy & Claims Editing Expertise
Research and interpretation of healthcare policies and regulations
Experience in reimbursement policy writing and claims editing
Proficiency in data mining to detect errors and inconsistencies
Ability to crosswalk and compare edits and policies
Knowledge of claims editing processes, including Prepay/Post-Pay, COB, Subrogation, Fraud Detection, and Medical Record Reviews
Contract Configuration & Provider Data Expertise
Interpretation of provider contract terms and pricing methodologies, including fee schedules, per diem, DRGs, cost-plus, and outlier payments
Understanding of contract carve-outs, including bundled services, readmissions, and reductions
Experience in contract pricing and claims reimbursement analysis
Ability to price and reprice claims based on contractual agreements
Understanding of provider TIN and NPI relationships
Knowledge of the provider lifecycle, including Credentialing, Data Management, Contracting, and Configuration
Familiarity with network processes, including Optimization, Adequacy, and Pricing
Familiarity with claims adjudication systems (e.g., Facets, QNXT, Amisys, etc.)
Based in Chicago, IL, and flexible to work from our Chicago office as needed