Job Description

Responsibilities

:
  • Review/approves and audits Payment Integrity (PI) vendor and internal prospective and retrospective edits/projects/recoveries
  • User Acceptance Testing (UAT)/Client Review & audit (provider data, Appian Advanced Group ID (AGID) configuration, and set-up concentration) reviews requests prior to initial submission to Enterprise Operations (EO) and claims post-production
  • Facets claims edit configuration concentration (Appian) – intake, review, impact assessment, and initial submission; UAT reviews requests prior to initial submission to EO and claims post-production
  • Encounter error reconciliation representation, oversight and management – including identification and initiation of claim or provider changes necessary to mitigate/prevent future errors
  • Management and resolution of state complaints
  • State policy and contract amendment changes analysis and management
  • Internal or vendor medical policy or Health Value Opti...

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