Who you are:

As a Senior Payment Integrity Analyst, you are the Subject Matter Expert on the Health Plan's payment policies and coding topics. You can build an algorithm for our payment integrity library with the full understanding of the plan's product benefits, fee schedules, claims edits, provider agreements, and claims processing rules. You understand the importance staying abreast of all coding guidelines, industry-standard rules, and health plan claims operations to ensure the team is capturing all potential opportunities.

What you'll do:

• You will be responsible for the development of new concepts for the Health Plan Payment Integrity Department (PI) to include research & development of new payment error projects/reports based on provider contract analysis and industry trends.
• You will analyze and interpret Health Plan's product benefits, fee schedules, claims edits, provider agreements, and claims processing rules to assist with building algorithms for payment integrity library.
• Develops functional and operational flows and procedures for approved system enhancements or modifications
• You will collaborate closely with auditors to create new algorithms, and ad hoc reports to find overpayments
• You also work closely with the Data Scientists and Analytics team to provide business requirements necessary for algorithm development New ideations include Fee Reimbursement, Payment Policy, Benefit Configuration, COB, or Medical Policy rules used to ensure proper pre and post payments

What you’ll bring:

• 5+ years’ experience in medical billing, claims auditing, claims analysis
  • Functional understanding of health care claim data sets such as ICD-10, CPT, DRGs and APCs
• 5+ years investigating, researching, and analyzing claims data applying knowledge of medical or pharmacy policy to determine details of the overpayment
• Ideally, you have had exposure in the development of new concepts for the Health Plan Payment Integrity Department (PI) to include research & development of new payment error projects/reports based on provider contract analysis and industry trends.
• Previous experience within Payment Integrity ideation unit is preferred.
• Ability to retrieve and analyze data using Microsoft Excel, Access, and SQL.
• You will bring a comprehensive understanding of managed care operations including terminology and claims processing.
• Comprehensive understanding of reimbursement methodologies, along with state and federal regulations and applicable industry standards.
• Strong verbal and written communication skills with demonstrated ability to research, problem solve and trouble shoot.
• Proven ability to work independently while managing multiple tasks and priorities.
• Bachelor’s Degree in Business, HealthCare Management or related field preferred. Additional related work experience may substitute for some educational requirements.

• Bachelor’s Degree in Business, HealthCare Management or related field preferred. Additional related work experience may substitute for some educational requirements. Master’s Degree preferred.

Who we are:

Johns Hopkins Health Plans (JHHP) is the managed care and health services business of Johns Hopkins Medicine. JHHP is a $3B business serving over 500,000 active members with lines of business in Medicaid, Medicare, commercial, military health, health solutions, and venture investments. JHHP is a leader in provider-sponsored health plans and is poised for future growth.

Many organizations talk about transforming the future of healthcare, at Johns Hopkins Health Plans, we are setting the pace for change within the healthcare industry. We develop innovative, analytics-driven health programs in collaboration with provider partners to drive improved quality and better health outcomes for our members and the communities we serve. If you are interested in improving how healthcare is delivered, and have a passion to be at the forefront of change, JHHP is the place to call home.

Please note : US citizenship is required for this position as it falls under the terms of a government contract (to ensure compliance with DODPSP).

Johns Hopkins Health System and its affiliates are an Equal Opportunity / Affirmative Action employer.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.

Johns Hopkins Health System and its affiliates are drug-free workplace employers.