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Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

Job Summary

The Sr Provider Audit Analyst is responsible for review of claims for accuracy of coding, benefit, payment, and contract interpretation in accordance to claims processing guidelines, Point32Health Medical and Payment Policies and established audit protocols. He/she compiles and analyzes data to identify inaccurate payments and trends for root cause analysis. This position is responsible for recovery of inaccurate payments including, analysis, drafting of recommendations, securing approvals, coordination of adjustments with claims and tracking of outstanding dollars. The candidate for this position should be able to think critically about contract and/or policy related issues that have a significant financial, operational and relationship impact to Point32Health as well as to its entire provider community. Coding Certification (CPC, CCS or equivalent); Maintenance of credential status.

Job Description

Key Responsibilities/Duties – what you will be doing (top five):

+ Accountable for the overall quality and accuracy of assigned individual audits as well as the accompanying data mining, analytics, and summary reporting.

+ Typically manage $.5M to 1M each in recoveries/year. Utilize comprehensive knowledge of CPT, HCPCS, ICD10-CM diagnosis and procedure codes to assist in claims data analysis related to policies and recovery identification.

+ Coordinates findings and recoveries with multiple departments across the organization including but not limited to: Contracting, Claims, SIU, and Finance.

+ Responsible for all aspects of project analysis from: conceptualization, development of queries, programming, execution, problem identification, and resolution, recovery, reporting and recommendations.

+ Integrates data from multiple internal and external resources to develop and present recommendations for recoveries to management.

+ Other duties and projects as assigned.

Qualifications – what you need to perform the job

Certification and Licensure

+ CPC, CCS or Equivalent

Education, Certification and Licensure

+ Required (minimum): Bachelor’s degree in a related field

+ Preferred: Master’s degree

Experience (minimum years required):

+ Required (minimum): 5-7 years of related professional healthcare experience including familiarity with medical claims processing.

+ Preferred: 8-10 years of related work experience

Skill Requirements

+ Excellent analytic, critical thinking and organizational skills, including knowledge of analytic and statistical concepts, techniques, and methods.

+ Proven ability to function independently and creatively.

+ Proven analytic experience and skilled at manipulating, analyzing, and evaluating large data sets at various levels of detail; knowledge of SAS or other programming language (SQL) and advanced use of MS Access and Excel.

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

+ Must be able to work under normal office conditions and work from home as required.

+ Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.

+ May be required to work additional hours beyond standard work schedule.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Compensation & Total Rewards Overview

As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law.

Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

+ Medical, dental and vision coverage

+ Retirement plans

+ Paid time off

+ Employer-paid life and disability insurance with additional buy-up coverage options

+ Tuition program

+ Well-being benefits

+ Full suite of benefits to support career development, individual & family health, and financial health

For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/

Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity

•Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

**Scam Alert** : Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact [email protected]

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.