Job Description

At Memorial Hermann, were about creating exceptional experiences for both our patients and our employees. Our goal is to provide opportunities for our diverse employee population that develop and grow careers in a team-oriented environment focused on patient care.

Every employee, at every level, begins their journey at Memorial Hermann learning about the history of the organization and its established culture built on trust and integrity. Our employees drive this culture, and we want you to be a part of it.

Job Summary

Position is responsible for conducting moderate to complex analysis to ensure appropriate payment is made for health plan members, according to contractual terms, and free of wasteful and abusive practices for all medical/pharmacy claims. Executes Payment Integrity tasks such as claims payment and recovery activities, pre/post payment audits, and research and investigative functions to meet customer and regulatory requirements. This role ensures over/underpayments risks are minimized and that to the extent payment issues are identified, they are remedied and/or escalated quickly. Typically reports to a Network Operations Leader.

Job Description

Minimum Qualifications:

Education:High School diploma; Bachelors in Business or Healthcare field preferred

Licenses/Certifications: (None)

Experience / Knowledge / Skills:

* Five (5) years of experience working in a healthcare data or regulatory environment; payment integrity preferred
* Effective oral and written communication skills for influence and negotiation.
* Knows how to obtain and use data, and comfortable with statistical concepts
* Strong interpersonal skills to work with all levels across all functional areas to include internal business partners
* Healthplan experience in facility contract configuration, claims or IT
* Strong understanding healthcare claims data, pricing and claims editing concepts, including UB04 and HCFA 1500 claim content
* Experience with Microsoft Word, Excel, PowerPoint, Visio
* Preferred systems knowledge Facets, NetworX Pricer, CES, Cerner, 3M, Tableau
* Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of we advance health through innovation, accountability, empowerment, collaboration, compassion and results while ensuring one Memorial Hermann.

Principle Accountabilities:

* Uses data analytic expertise to assist in the development of enhanced payment integrity, fraud, waste and abuse analytic tools, reporting capabilities, reimbursement policy and identification of operational efficiencies
* Researches, compiles, interprets, and documents data to develop appropriate specifications for testing and deploying reimbursement solutions and complex reimbursement initiatives
* Conducts regulatory research to determine revisions/updates to various federal and state payment requirements for hospital, ambulatory surgery, and physician providers
* Consults and coordinates with various internal departments, external resources, business partners, and government agencies.
* Documents operational and technical workflows
* Configures and customizes software solutions
* Works closely with clinical personnel to ensure alignment with clinical and benefit policies
* Reviews technical documents and specifications for compliance with operational procedures
* Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
* Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
* Other duties as assigned.