Payment Accuracy Analyst

The Payment Accuracy Analyst is a key role responsible for supporting the Claim Editing team within UPMC Health Plan’s Reimbursement Department. Functions include collaborating with external payment accuracy software vendors with regard to the implementation and maintenance of industry-standard clinical coding edits. Additionally, participates in cross-functional efforts including the Claims Operations, Systems Configuration, Medical Policy, & IT departments, and acts as a liaison between external vendors and internal stakeholders in the development and maintenance of claims payment and medical policy edits based on clinical, financial, and operations perspectives. The Payment Accuracy Analyst is also accountable for ongoing report analysis that identifies areas of potential savings, along with ensuring payment accuracy and payor (i.e. Medicare, Medicaid) compliance.

This position will work in a hybrid work structure. 

Responsibilities:

• Provide in-depth analysis of professional and facility claims routed to the manual claims validation queue based on new or updated edit logic.
• Create and maintain documentation aimed at promoting consistency in validations and claims workflow process improvements.
• Maintain current industry knowledge of claim edit references including, but not limited to: AMA, CMS, and NCCI.
• Advise management if edits are working as intended and support decisions with validation data.
• Aid and support team members with reviewing complex or escalated member and provider appeals for accurate payment and processing by industry-standard coding guidelines.
• Assist in monitoring, researching, and tracking changes as UPMC Health Plan payment and medical policy changes.
• Identify and provide root-cause analysis of claim edit performance issues.
• Conduct research and analysis for medical policy items for configuration of payor policy sourced edits; work with department leadership to determine how they can be configured to comply with UPMC Health Plan-specific clinical and payment policy.
• Assist in the submission of IT requests associated with validations and the enhancement of reports/tools needed to maximize results.
• Work closely with the Manager and Director of Claim Editing in departmental functions and special projects.
• Document daily claims performance for claim edits and advise management of any significant performance issues immediately.