The Insurance Payment Variance Analyst performs day-to-day payment variance activities within the Hospital and/or Medical Group revenue operations for South Shore Health. The scope of responsibility will be resolution of all open claim payment variances (overpayments and underpayments) for 20 insurance payors loaded into Experian. Additionally, this role researches the root cause of variances and utilizes historical data to provide detailed analytical summaries for South Shore leaders. Serves as part of the Payment Variance team responsible for ensuring proper claims payments are received from insurance companies, determining root causes for discrepancies, minimizing inappropriate payment delays and variances from expected reimbursement, and resolving or escalating issues to the Manager for resolution. Experience with insurance billing/claim appeals for professional and/or hospital claims strongly preferred. This is a hybrid position and reports directly to the Supervisor.
Investigates and addresses overpayment and underpayment hospital and professional claim accounts with the objective of appropriately optimizing reimbursement for services rendered.
Ensures that claims are paid/settled in the timeliest manner possible:
Strategically applies knowledge of specific insurance payer payment rules, managed care contracts, reimbursement schedules, eligible provider information and other available data and resources in order to research payment delays and variances, make corrections, and take appropriate corrective action to ensure timely claim resolution. ]
Proactively follows up on payment delays and variances by contacting patients and third-party payers, and supplying additional data, as required.
Conducts ongoing analysis of contract compliance and financial performance for third-party payers to provide leadership with support during payer contract negotiations
Supports payer strategy teams by reviewing and comparing regular contract/rate adjustments provided by payers
Researches and provides data independently for recommendations used in payer negotiation processes
Reports and maintains data on types of variances and root cause. Collaborates with management and team to make recommendations for improvements.
Analyzes and researches historical data loaded into Experian to trend and identify ongoing issues for specific payors or plans
Samples aged variance accounts within Epic to identify root cause, carrying forward that knowledge for future recommendations
Utilizes data files to create visualizations to support the variance coordinator in meetings with South Shore Revenue Cycle leadership
Develops analytical performance dashboards with key performance indicators, formulas, and other reimbursement related data to track historical reimbursement trends
Acts as the designated liaison for payers, as well as for other internal departments and leadership, regarding payment accuracy
Composes adjusted claims and appeal letters to resolve payment rejections.
Requests write offs, transfers, allowances, and reversals.
Documents all actions and encounters in the patient accounting system using standard codes.
Maintains working knowledge of the areas of third-party billing, reimbursement schedules and methodologies, coding, payer contracts, billing and payment rules and regulations, and hospital billing compliance
Actively participates in recurring trend research meetings with HB and PB Billing and Follow up teams, providing analytical insights from research conducted in the role
Excellent written and verbal communication skills and organizational abilities.
Strong interpersonal skills in interacting with internal and external customers.
Strong accuracy, attention to detail and time management skills.
Advanced understanding of Microsoft Office, including Outlook, Word, PowerPoint, and Excel.
Research and analytically oriented in work and analyses completed
Epic and/or Experian experience preferred but not required.
Detailed knowledge of reimbursement schemes for predominant payors.
Detailed knowledge of CPT-4, HCPCS, revenue codes and ICD-10 CM.
Completion of regulatory/mandatory certifications and skills validation competencies preferred.
Must be comfortable operating in a collaborative, shared leadership environment.
Hybrid work schedule!