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HEMA- Payer Performance Analyst and Auditor IV at Boston Scientific Corporation Malaysia

Houston, Texas, United States -

Full Time

Start Date

Immediate

Expiry Date

27 Jan, 26

Salary

0.0

Posted On

29 Oct, 25

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Payer Performance Monitoring, Data Analysis, Auditing, Regulatory Compliance, Medical Billing, CPT Coding, ICD-10-CM Coding, Data Management, Microsoft Office, Microsoft Dynamics, Contracting Support, Claims Processing, Data Validation, Operational Compliance, High Volume Data Requests, Payer-Specific Challenges

Industry

Medical Equipment Manufacturing

Description

Monitors assigned payers for high-level performance (manually creating scorecards pending automation). Produces and circulates payer analytical outcomes data to appropriate internal teams. Performs in-depth audits when payers challenge billing practices or rates and reports to HEMA / RCM staff. Performs formally assigned payer performance reviews under perspectives 1 & 2. Performs formally assigned non-contracted payer performance reviews to support contracting efforts. Performs audits of payer clinical and/or contractual policy or operational compliance. Performs regulatory audits as required and/or as requested by RCM, HEMA, legal and/or privacy. Supports HEMA Centers for Medicare and Medicaid Services (CMS) CERT audits per CERT data validation requirements. Performs high-volume data requests or SIU audits from insurers as assigned by HEMA staff. Supports assigned practice-requested payer-specific challenges as necessary to support or coordinate coverage issues and/or joint appeals. Supports other payer/data projects as assigned by HEMA. 3-5 Years with High School Diploma and/or Equivalent experience, training , or apprenticeships Proficient use of all Microsoft Office applications and internal tools is required. Familiarity with Microsoft Dynamics. Proficient knowledge of medical justification, authorizations, billing, and appeals. Ability to manage, sort, and assess large data reports to summarize requested analytics. Extensive knowledge of health care claims and basic regulatory billing requirements. Basic knowledge of CPT and ICD-10-CM coding. Basic knowledge of claim-by-claim medical appeals processing.

Responsibilities

The analyst monitors assigned payers for performance and produces analytical outcomes data for internal teams. They perform audits and reviews related to payer billing practices and compliance.