Payment Integrity Representative

Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland.

Work Shift:

8 Hours - Day Shifts (United States of America)

Scheduled Weekly Hours:

40

Compensation:

Salary Range: $19.00 - $30.50

Union Position:

No

Department Details

Small team of great, friendly co-workers with a lot of flexibility.

Summary

Responsible for reviewing, maintaining, and analyzing underpayment records and managed care contracts to ensure Sanford is paid according to contract terms for system billing, maximizing reimbursement, and maintaining compliant practices.

Job Description

Develop, document and oversee standard operating procedures in One Note to ensure consistency in business rules applied in claim adjudication. Possess in-depth understanding of the reimbursement techniques and strategies. Knowledge in reimbursement/payment classification systems, fee schedules and managed care contracts. Knowledge of Remark and Reason codes sent from payors as well as reading a remittance advice. Responsible for the appeals related to underpayments & overpayments according to Sanford's internal guidelines. Work with reimbursement analysis and testing by payor, analyze trending of managed care issues by payor, and assist in reviewing managed care activity in the system. Able to interpret and analyze complex managed care contracts and schedules to ensure payments received as contracted. Ability to analyze information objectively and draw a rational conclusion. Complete extensive research to determine if claims are being paid correctly per separate guidelines that payors have that are not part of Sanford contracts. Lift up payment processing policies that are being deployed by the payors to Sanford Contracting team.

Identify errors by operational departments, research and provide guidance on how coverage should be set up. Identify and communicate enrollment issues when new payors are brought on. Identify systemic issues with payor claim systems by investigating and finding patterns of claim variances. Facilitate education and distribution of relevant information to internal departments and payors. Ability to call payors to help identify the issue on a particular underpayment, being able to collate well for final resolution.

Support billing and finance in developing and conducting analysis and reporting to aid operational decision making. Committed to working in a fast-paced, high-volume, and changing environment and have a high energy level and the ability to accomplish objectives. Cultivate positive working relationships with management, staff and other departments. Skilled in negotiation, able to build consensus while managing the delicate managed care relationships between system and payors.

Qualifications

Associate degree in healthcare or business related field required or in lieu of education will accept a minimum of three years prior healthcare revenue cycle experience.

Experience working with Excel spreadsheets required. Minimum two years prior healthcare experience with an understanding of healthcare reimbursement preferred.

Must meet standard productivity requirements prior to moving to a home-based position; if meeting productivity requirements but with less than one year working in Sanford office, must have Director approval to move to a home-based position.

Sanford is an EEO/AA Employer M/F/Disability/Vet.

If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-949-5678 or send an email to talent@sanfordhealth.org.

The Sanford organization owns and manages multiple distinct brands, including Sanford Health, Marshfield Clinic, and Good Samaritan, as well as Lewis Drug, Sanford Health Equip, Solutions by Sanford, Great Shots, and Blue Rock Bar & Grill.

About Sanford Health

Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland. Headquartered in Sioux Falls, South Dakota, the organization has 53,000 employees and serves over 2 million patients and nearly 425,000 health plan members across the upper Midwest including South Dakota, North Dakota, Minnesota, Wyoming, Iowa, Wisconsin and the Upper Peninsula of Michigan. The integrated nonprofit health system includes a network of 56 hospitals, 288 clinic locations, 147 senior care communities, 4,000 physicians and advanced practice providers and nearly 1,500 active clinical trials and studies. The organization’s transformational virtual care initiative brings patients closer to care with access to 78 specialties. Learn more about Sanford Health’s commitment to shaping the future of rural health care across the lifespan at sanfordhealth.org or Sanford Health News.

About Good Samaritan

Good Samaritan, one of the nation’s largest nonprofit providers of senior care and services, is committed to transforming the aging experience through innovation, compassion and personalized care. As part of Sanford Health, an integrated nonprofit health system headquartered in Sioux Falls, South Dakota, Good Samaritan serves 10,000 seniors and offers access to a full continuum of care, including 94 rehabilitation and skilled nursing centers, 56 assisted living and memory care facilities, 44 independent living locations and 37 home health and hospice agencies. The senior care provider delivers services across the upper Midwest, with 70% of residents living in rural communities. Learn more about Good Samaritan’s mission and commitment to delivering high quality senior care in rural America at good-sam.com.