About City of Hope
City of Hope is an independent biomedical research and treatment organization for cancer, diabetes and other life-threatening diseases.
Founded in 1913, City of Hope is a leader in bone marrow transplantation and immunotherapy such as CAR T cell therapy. City of Hope's translational research and personalized treatment protocols advance care throughout the world. Human synthetic insulin, monoclonal antibodies and numerous breakthrough cancer drugs are based on technology developed at the institution. AccessHope™, a subsidiary launched in 2019 serves employers and their health care partners by providing access to City of Hope's specialized cancer expertise.
A National Cancer Institute-designated comprehensive cancer center and a founding member of the National Comprehensive Cancer Network, City of Hope is ranked among the nation's "Best Hospitals" in cancer by U.S. News & World Report and received Magnet Recognition from the American Nurses Credentialing Center. Its main campus is located near Los Angeles, with additional locations throughout Southern California and in Arizona.City of Hope's commitment to Diversity, Equity and Inclusion
We believe diversity, equity and inclusion is key in serving our mission to provide compassionate patient care, drive innovative discovery, and advance vital education focused on eliminating cancer and diabetes in all of our communities. Our commitment to Diversity, Equity and Inclusion ensures we bring the full range of skills, perspectives, cultural backgrounds and experiences to our work -- and that our teams align with the people we serve in order to build trust and understanding. We are dedicated to fostering a community that embraces diversity - in ideas, backgrounds and perspectives; this is reflected in our work and represented in our people.Position Summary
The Senior Payment Integrity Recovery Analyst is responsible for City of Hope's reimbursement integrity by conducting payment discrepancy analyses, initiating underpayment reclamation, monitoring payment activity, and communicating with payors. This position serves as a key individual contributor towards City of Hope's practice to maintain its relations with third-party payors while upholding contracts and confirming reimbursement objections are achieved.Key Responsibilities include:
- Performs due diligence to ensure accuracy in City of Hope's collections and recovers any funds related to underpayments.
- Performs analyses of payment trends by payor, contract, revenue code, HCPCS, claim type, patient class, etc. to identify underpayments. Monitors, evaluates and reviews all cost reporting in support of claims.
- Performs algorithm research, development, and maintenance for the purpose of processing hospital data to identify underpayments. Analyze correspondence to identify strategies that determine future pipeline opportunities. Support team efforts in leading concepts/projects to completion/implementation, and perform necessary research of governmental regulatory agencies for reference as needed.
- Conducts various mathematical calculations to determine the degree of false positive underpayments, and/or verifies the contract accuracy rate to report to the ConnectHope Contract Analyst.
- Identifies and documents root causes of overpayments along with remediation recommendations. Works with payors to recover underpayments including follow-up calls and written appeals.
- Remains current with payor contracts and billing regulations to identify accurate payment methodology and misuse, resolve accounts with discrepancies from expected payment to ensure compliance with the contracted terms that pertain to payment methodologies and reimbursement practices.
- Closely examines payor contract language and translate into data modeling to facilitate proper pricing.
- Performs comprehensive research and analyses of claims data to determine and/or identify billing abnormalities, practices or abusive billing activity. To address the misuse of payment agreements that trigger underpayments, maintains consistent, professional communication with payors, administers follow-up efforts (via email, phone, payor portal websites), and/or issues appeal letters.
- Collaborates with various staff (e.g., collectors, Sr. Billing Managers, etc.) to identify common causes of underpayments. Consistently meet work/performance standards that include payment integrity goals, productivity, quality metrics and monthly savings goals.
- Attends meetings within the Business Office to communicate any observed variances that may contribute to under payments, and helps identify process improvements to prevent underpayments in the future. Adapts to the departmental plans and priorities to address business and operational challenges.
- Develops and implements procedures for filing reimbursement claims and ensures timely and accurate claims payment. Serves as resource for staff, and payors seeking to resolve questions and/or concerns related payment variances.
- Through demonstration and leadership, ensures that services are provided in accordance with state and federal regulations, organizational policy, and accreditation/compliance requirements
- Research and proactively apply new hospital regulations and legislations. Prepares and submits strong appeals that result in revenue recovery for all types of denials including contract underpayments, billing issues, payor error denials, etc.
- Interact effectively with internal teams to assist data reviews or claim resolution
Follows established City of Hope and department policies, procedures, objectives, performance improvement, attendance, safety, environmental, and infection control guidelines, including adherence to the workplace Code of Conduct and Compliance Plan. Practices a high level of integrity and honesty in maintaining confidentiality.
Performs other related duties as assigned or requested.Basic education, experience and skills required for consideration:
Preferred education experience and skills:
- BA/BS - Economics/Finance/Accounting/Business/Healthcare Administration. Experience may substitute for education requirement
- 5 years of experience in Healthcare accounting, finance, preferably with payor contracts
- Strong analytical, quantitative skills, and data modeling highly preferred
- As a condition of employment, City of Hope requires staff to comply with all state and federal vaccination mandates.
City of Hope is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, sexual orientation, gender identity, age, status as a protected veteran, or status as a qualified individual with disability.