Payment Accuracy Specialist 2 (Data Mining)

Overview

A Payment Accuracy 2, Data Mining (DM) Specialist, is a member of the greater Data Mining Business Unit (BU). Cotiviti’s Data Mining team configures custom claim reviews to investigate untapped billing compliance issues specific to regulations and contracted policies across product, market, and provider types.

The Specialist 2, Payment Accuracy is responsible for developing new and existing audit concepts, gaining client acceptance, training all Specialist levels to execute audit projects, and evaluating the effectiveness of audit concepts.  Audits client data and generates high quality recoverable claims for the benefit of Cotiviti and our clients.  Conducts and trains more complex audit projects with some to limited supervision.  Considered a mentor, trainer, and developer of less-tenured team members.   Displays a high degree of independent judgment and professional skepticism that enhances the work performed in order to achieve success in the position.

Responsibilities

  • This individual will work under moderate supervision and will be monitored for efficiency in production and quality review of assigned work.
  • Has the ability to build and maintain a basic understanding of Centers for Medicare and Medicaid Services (CMS) and National Association of Insurance Commissioners (NAIC) guidelines to establish the correct order of liability.
  • Advanced with Cotiviti audit tools Recovery Management System (RMS), specific client systems) to complete auditing, review simple – medium proprietary reports, has an expert understanding of Microsoft Excel and client applications
  • Utilizes healthcare experience to perform audit procedures that include identifying and defining issues, developing criteria, reviewing, and analyzing evidence with the intent to audit medium and complex reports. Work is advanced in scope and complexity.   Knowledge is applied to resolve routine issues, as necessary. The scope may include Data Mining, Claim Adjudication, Contract Compliance, Provider Billing & Duplicate Payment Reviews, Policy & Reimbursement Analysis, and Quality Assurance. 
  • Advanced analysis of paid claims and identification of audit findings including documentation for training and knowledge sharing. Works with Engineering to increase the efficiency of tools and reporting.
  • May update current reports, develop and run custom queries and validate the accuracy of current reports used. Makes determinations based on prior knowledge and experience of client contract terms with the likelihood of recovery acceptance.  
  • Meets or Exceeds Standards for Productivity in addition to regular and predictable attendance, maintains production goals and standards set by the audit for the auditing concept. Achieves the expected level of quality and quantity for assigned work (i.e. hit rate, claims written, vendor/project volume completion, ID and/or fees per hour)
  • Meets or Exceeds Standards for Quality by Achieving the expected level of quality set by the audit for the auditing concept, for valid claim identification and documentation.
  • Highly proficient, subject matter expert in responding to inquiries and disputes received on all claims written. Provides verification of claims validation and confirmation, in a concise written manner, utilizing facts and details for justification purposes.
  • Demonstrates aptitude in reviewing transaction types, client contracts/vendor agreements, and client data with limited supervision of how to identify potential over or underpayments. Makes recommendations on medical policy applications, state and federal statutes, and other reimbursement methodologies as it applies to the audit concept. 
  • Considered a skilled resource in onboarding new hires and/or training existing staff on new concepts and processes.
  • Identifies New Claim Types & Concept Expansion by using proven methodologies to research and substantiate claims outside the audit concept. Enlists others internally or externally to help validate, suggest, develop, and analyze high-quality, high-value concepts and/or process improvements, tool enhancements, etc.  Strong driver and voice in the development of audit concepts.
  • Recommends New Concepts & Processes based on experience and in-depth knowledge of client contract terms and complex claim types. Has a proven record of developing and implementing new ideas, approaches, and/or technological improvements that support and enhance audit production.  Uses advanced validation methods to test and produce a desired/intended result of the new concept. Regularly collaborates with Engineering in the development of new reports and tool functionality.
  • Demonstrates understanding of Cotiviti policies & procedures, and external regulatory requirements and performs duties in accordance with such regulatory requirements
  • Ensures confidentiality and security of all data, adhering to all HIPAA (Health Insurance Portability and Accountability) laws and requirements. Demonstrates the skills, knowledge, and ability to ensure that our environment is safe, complying with industry standards.

Qualifications

  • High School Diploma – Required
  • Bachelor’s degree (Preferred) and/or a minimum of at least (4 – 6) year/s related experience in healthcare.
  • At least 3 – 4 year/s of Cotiviti experience is recommended for individuals seeking their next opportunity internally.
  • Healthcare industry experience, including knowledge of Coordination of Benefits. (Preferred).
  • Computer proficiency including Microsoft Office (Word, Excel, Outlook, Access)
  • Excellent verbal and written communication skills.
  • Strong interest in working with large data sets and various databases.
  • Ability to work well in an individual and team environment demonstrating self–motivation to deliver success.
  • Understands and embodies Cotiviti Core Values, Strategic Pillars, and Operations Disciplines to achieve successful performance in completing assigned responsibilities and interactions with the Organization both internally and externally.

Mental Requirements:

  • Communicating with others to exchange information.
  • Assessing the accuracy, neatness, and thoroughness of the work assigned.

Physical Requirements and Working Conditions:

  • Remaining in a stationary position, often standing or sitting for prolonged periods.
  • Repeating motions that may include the wrists, hands, and/or fingers.
  • Must be able to provide a dedicated, secure work area.
  • Must be able to provide high-speed internet access/connectivity and office setup and maintenance.
  • No adverse environmental conditions expected.

Base compensation ranges from $29.00 to $33.00. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs. This role is eligible for discretionary bonus consideration.

Cotiviti offers team members a competitive benefits package to address a wide range of personal and family needs, including medical, dental, vision, disability, and life insurance coverage, 401(k) savings plans, paid family leave, 9 paid holidays per year, and 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti. For information about our benefits package, please refer to our Careers page.

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Cotiviti is an equal employment opportunity employer. Cotiviti recruits, hires and promotes individuals based on their qualifications for a specific job. Cotiviti values its diverse workforce and its selection of employees is made without regard to race, color, creed, sex, age, religion, pregnancy, childbirth or pregnancy-related conditions, national origin, sexual orientation, gender identity, marital status, genetic carrier status, military service, veteran status, disability, or any other category of class protected by federal, state or local laws. All employment decisions and personnel actions, such as hiring, promotion, compensation, benefits, and termination, are and will continue to be administered in accordance with, and to further the principle of, equal employment opportunity.

Pay Transparency Nondiscrimination Provision
Cotiviti will not discharge or in any manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-I.35(c)

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