Director Payment Integrity Jobs in Virginia (NOW HIRING)

Consultant,Payment Intelligence

AArete is one-of-a-kind when it comes to consulting firm culture.

We're a global, innovative management and technology consulting firm with offices in the U.S. and India. Our name comes from the Greek word for excellence: "Arete." And excellence is exactly what we strive for.

We're celebrating our fourth year as one of Forbes' World's Best Management Consulting Firms - and our success starts with our people. From robust career development planning to competitive life and wellness benefits, AArete's "Culture of Care" takes a holistic approach to the employee experience.

AAretians (our team members) are leaders at every level. You are encouraged to unlock your full potential by directly contributing to our mission and prioritizing personal development and fulfillment.

The Role

Health plans face continued challenges in reimbursing claimson-timeand accurately.AArete'sconsulting service line,Payment Intelligence,goes beyond typical payment integrity to ensureerroneousand inefficient payments areidentified, rectified, andrecouped toprevent them in the future. Our Payment Intelligenceteamaddresses issues with payment policies, provider contracts, provider data, covered benefits, member eligibility and priorauthorizations.

In this role, the individual willbe responsible forclient delivery ofPayment Intelligence.The position willreporttoa PaymentIntelligenceManager.The individual will be the subject matter expert on strategies to help our clients ensure proper claims paymentthrough the use of(1) claims analytics, (2) process improvements, (3) integration of automation/technology, and (4) configurations setups.This role will support the internal development of Payment Intelligence initiativesincluding research and interpretation of healthcare policiesandregulations,and experience inclaims editing.

WorkYou'llDo

• Supportthe development,identificationandanalysisof payment accuracy opportunities through remediation with clientcounterparts
• Utilize analytics toidentifyclaimspayment opportunities through your knowledge of standard payment methodologies including Prospective Payment Systems (IPPS/OPPS), fee for service, Groupers, RUG, etc.
• Support process improvements andautomationinitiativesforclients
• Conduct research oncurrent events, changes in regulatory requirements and market trendsimpactinghealth plan reimbursement
• Contribute to the preparation ofclient readydeliverableswith clear and actionable insight
• Exercisesoundjudgement and clear and direct communication in all aspects of your work
• Other duties as assigned

Requirements

• 2+ years of experience ina role withinconsulting, provider revenue cycle, a payment integrity vendor,and/or a payer organization
• Foundational knowledge ofclaims processing across multiple lines of business, including Medicare, Medicaid, ACA/Marketplace, Commercial, and Duals
• Experience across variousspendareas, including professional, ancillary, outpatient, and inpatient services
• Ability toidentifyand analyzemispaidclaims to ensure accuracy and compliance
• Knowledge of industry vendors and tools related to claims processing, provider data, and contract management
• Understanding of end-to-end claims processes, including claims management, provider lifecycle, and network optimization
• Strong professional communication skills, including written, verbal, interpersonal, and in-person presentationexpertise
• Experience coaching and mentoring team members
• AdvancedproficiencyutilizingMicrosoft Excel
• Strong analytical, data interpretation, and problem-solving skills
• Ability toidentifyclient savings opportunities and develop actionable business cases
• Bachelor's Degree or equivalent
• Direct client interactionwithpossibletravelto client locations
• Must be legally authorized to work in the United States without the need for employer sponsorship

Preferred Requirements

• Policy & Claims Editing Expertise
  • Research and interpretation of healthcare policies and regulations
  • Experience in reimbursement policy writing and claims editing
  • Proficiencyin data mining to detect errors and inconsistencies
  • Ability to crosswalk and compare edits and policies
  • Knowledge of claims editing processes, including Prepay/Post-Pay, COB, Subrogation, Fraud Detection, and Medical Record Reviews
• Contract Configuration& Provider Data Expertise
  • Interpretation of provider contract terms and pricing methodologies, including feeschedules,per diem, DRGs, cost-plus, and outlier payments
  • Understanding of contract carve-outs, including bundled services,readmissions, and reducti