Payment Accuracy Specialist 1 (Pharmacy DM)

Overview

A Payment Accuracy 1, 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 Payment Accuracy 1, Data Mining (DM) Specialist is responsible for auditing client data and generating high quality recoverable claims for the benefit of Cotiviti and our clients.  Responsible for conducting or assisting in the identification, validation, and documentation of moderate to more complex audit projects.  Documents relevant facts, information, and conclusions drawn to support the work performed and validate the claim.  Utilizes this information to knowledge share within the audit team.  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 direct 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.
• Proficient with Cotiviti audit tools Recovery Management System (RMS), specific client systems) to complete auditing, review simple - medium proprietary reports, has an advanced understanding of Microsoft Excel and client applications.
• Draws on prior experience to audit standard reports and paid claims to identify over and under-payments of claims.  The scope may include: Data Mining, Claim Adjudication, Contract Compliance, Provider Billing & Duplicate Payment Reviews, Policy & Reimbursement Analysis, and Quality Assurance.  Assigned to medium/complex reports. 
• Enters overpayments into Cotiviti system accurately and in accordance with standard procedures. Identifies and discusses audit findings with the audit team as a part of knowledge sharing and concept expansion.     
• 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.
• Responds effectively to inquiries received on 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 application, state and federal statues, and other reimbursement methodologies as it applies to the audit concept.
• Participates in onboarding new hires and cross-training efforts.
• Identifies New Claim Types & Concept Expansion by researching and identifying potential claims outside the audit concept.  Suggests, develops, and analyzes high quality, high value concepts and/or process improvements, tool enhancements, etc. 
• Recommends New Concepts & Processes by leveraging knowledge of client, contract terms, and complex claim types. Works towards developing and implementing new ideas, approaches, and/or technological improvements that will support and enhance audit production.  Evaluates information and draws logical conclusions.  Uses learned, tried, and proven validation methods to test and produce the desired/intended result of the new concept.  May collaborate with Engineering in the development of new reports.
• 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.
• Complete all responsibilities as outlined on annual Performance Plan.
• Complete all special projects and other duties as assigned.
• Must be able to perform duties with or without reasonable accommodation.

Qualifications

• High School Diploma - Required.
• Bachelor’s degree (Preferred) and/or a minimum of at least (2 - 4) year/s related experience in healthcare.
• At least 2 - 3 year/s of Cotiviti experience is recommended for individuals seeking their next opportunity internally. (Example: Audit Support positions).
• 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 $25.00 to $29.00 per hour. 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.

Nonexempt employees are eligible to receive overtime pay for hours worked in excess of 40 hours in a given week, or as otherwise required by applicable state law.

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.

Date of posting: 1/21/2025

Applications are assessed on a rolling basis. We anticipate that the application window will close on 2/21/2025, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected.

#LI-Remote#LI-KB1#junior