Payment Integrity Analyst
Rialtic is an enterprise software platform empowering health insurers and healthcare providers to run their most critical business functions. Founded in 2020 and backed by leading investors including Oak HC/FT, F-Prime Capital, Health Velocity Capital and Noro-Moseley Partners, Rialtic's best-in-class payment accuracy product brings programs in-house and helps health insurance companies gain total control over processes that have been managed by disparate and misaligned vendors. Currently working with leading healthcare insurers and providers, we are tackling a $1 trillion problem to reduce costs, increase efficiency and improve quality of care. For more information, please visit www.rialtic.io.
If you describe yourself as a healthcare coding and billing policy geek who is passionate about payment accuracy and integrity, then this is the dream job you’ve been looking for. As a Healthcare Content Analyst, you’ll research and interpret CMS, CPT/AMA and other major payer policies based on healthcare correct coding and regulatory requirements. You’ll identify common error areas that can be made into automated software logics that prevent overpayments from occurring. You’ll take your edits from concept to specification and then through review, testing and finally data validation - along the way you’ll collaborate with some of the smartest minds in healthcare policy and technology.
Your goal everyday is to develop claims editing logics that promote payment accuracy and transparency across Medicaid, Medicare, and commercial lines of business. You’ll increase your revenue cycle acumen as you identify ways to turn resource excerpts into claims processing rules that educate payers and providers on why a claim should not be paid.
- Review healthcare policy (Medicaid manuals, fee schedules, CCI, OIG Alerts, LCAs/LCDs, NCDs, Medicare manuals, etc.) for coding and billing guidelines that can be turned into software editing rules
- Create billing edits that provide clients with monetary savings and promote coding accuracy
- Use structural design to turn policy language into specifications that developers turn into software coding edits or logics
- Build unit tests to verify the functionality of the edits
- Apply revenue cycle, coding, and billing expertise to interpret policy based on correct coding, billing, and auditing guidelines
- Provide in-depth research on regulations and support edits with official documents
- Validate if edits are working as intended and support decisions with validation data
- Maintain current industry knowledge of claim edit references including, but not limited to: AMA, CMS, NCCI
- Collaborate with the Content and Engineering & Data teams to develop, adjust, and validate edits
- Provide subject matter expertise on several professional claims top error areas in coding and billing across multiple specialties
- Independently meet weekly productivity and quality goals
- Be a self-starter and remain driven while independently working remotely (hybrid in Atlanta preferred).
- 2-5+ years of claims editing experience with healthcare payers and/or claims editing software vendors
- Nationally recognized coding or billing credential required: CCS, CCS-P, CPC, CPB
- Billing, coding, revenue cycle, and claims editing software experience
- Experience in claims adjudication and application of NCCI editing and multiple payment rules
- Ability to interpret claim edit rules and references
- Solid understanding of claims workflow including the interconnection with claim forms
- Bonus: Intermediate level proficiency mapping CMS 1500, EDI and FHIR
- Ability to apply industry coding guidelines to claim processes
- Proven experience reviewing, analyzing, and researching coding issues for payment integrity
- Logics skills: ability to break policy edits down into decision making paths
- Ability to troubleshoot and apply root-cause analysis of logics not functioning as intended
- Computer skills: ability to use Google Work Space, Amazon Work Space, Jira, SmartDraw and other software with minimal training
- Intermediate level proficiency in Excel (ability to manipulate data using excel functions along with pivot tables, v-look up, etc).
- Excellent verbal & written communication skills
- Bonus: SQL query-building and lookup skills
- High Integrity
- Do the right thing. Provide candid feedback. Be humble and respectful.
- Customer Value Comes First
- Delivering value to our customers is our North Star.
- Work as One Team
- Collaborative, inclusive environment to advance our mission.
- Be Bold & Accountable
- Speak up. Take accountability. Continually improve.
- Pursuit of Excellence
- Innovate, iterate and chase the best possible outcomes.
- Take Care of Yourself & Others
- Prioritize the health and wellbeing of yourself and your teammates.
- Freedom to work from wherever you work best and a home office stipend to make it happen
- Meaningful equity and 401k matching
- Unlimited PTO, comprehensive health plans and wellness reimbursements
- Comprehensive health plans with generous contribution to premiums
- Mental and physical wellness support through TalkSpace, Teladoc and One Medical subscriptions