HEMA- Payer Performance Analyst and Auditor IV

Additional Location(s):  N/A

Diversity - Innovation - Caring - Global Collaboration - Winning Spirit - High Performance

At Boston Scientific, we’ll give you the opportunity to harness all that’s within you by working in teams of diverse and high-performing employees, tackling some of the most important health industry challenges. With access to the latest tools, information and training, we’ll help you in advancing your skills and career. Here, you’ll be supported in progressing – whatever your ambitions.       

Shift Hours: 8:00 AM -5:00 PM

About this role:
Boston Scientific Cardiac Diagnostic Services is an Independent Diagnostic Testing Facility (IDTF) that submits health care claims to both contracted third party insurers under national and local provider contracts and non-contracted insurance entities. The Payer Analytics and Auditing function requires a dual perspective approach (outlined below) that must be performed in sequence and in a fashion that would support any downstream contractual or non-contractual legal considerations. Payer audits can be initiated by the Health Economics and Market Access (HEMA) team to conduct contract performance assessments for new and existing contracts either on a routine basis or in situations of known payer non-compliance, or they may be assigned by the IDTF’s Revenue Cycle Management (RCM) team. Payers may also request audits of submitted claims.  

Perspective 1: Internal Contract Performance Review
This function assesses contractual terms, conditions, and/or regulatory requirements along with payer policy, identified operational requirements, and billing data to establish full operational compliance within the billing and collecting process.

Perspective 2: This function assesses claims outcomes to ensure contractual terms, conditions, and/or regulatory requirements were observed by payers as necessary to pay for covered services.

The process to perform audits under Perspective 1 includes a summery overview of claims outcomes to determine if a default audit should become a prerequisite to payer engagement. Default audits are in-depth reviews of claims as necessary to review internal operational processes to prepare evidence of internal operational opportunities for corrective action plans in cooperation with RCM. Default audits are equally required to prepare evidence of internal operational compliance as necessary to prepare evidence for payer presentations under Perspective 2.  
The process to perform audits under Perspective 2 includes acquiring internal documents demonstrating full compliance when Perspective 1 is not in default as well as claims outcomes documentation to be used as evidence in payer presentations to support appropriate payment or recoup payments that are in arrears. 

Work Mode 
At Boston Scientific, we value collaboration and synergy. This role allows a hybrid work model, requiring employees to be in our local office at least three days per week. 

Relocation
Relocation assistance is not available for this position at this time. 

VISA
Boston Scientific will not offer sponsorship or take over sponsorship of an employment VISA for this position at this time

Your responsibilities include:

• Monitors assigned payers for high-level performance (manually creating scorecards pending automation).
• Produces and circulates payer analytical outcomes data to appropriate internal teams.
• Performs in-depth audits when payers challenge billing practices or rates and reports to HEMA / RCM staff.
• Performs formally assigned payer performance reviews under perspectives 1 & 2.
• Performs formally assigned non-contracted payer performance reviews to support contracting efforts.
• Performs audits of payer clinical and/or contractual policy or operational compliance.
• Performs regulatory audits as required and/or as requested by RCM, HEMA, legal and/or privacy.
• Supports HEMA Centers for Medicare and Medicaid Services (CMS) CERT audits per CERT data validation requirements.
• Performs high-volume data requests or SIU audits from insurers as assigned by HEMA staff.
• Supports assigned practice-requested payer-specific challenges as necessary to support or coordinate coverage issues and/or joint appeals.
• Supports other payer/data projects as assigned by HEMA.

Required qualifications:

• 3-5 Years with High School Diploma and/or Equivalent experience, training , or apprenticeships
• Proficient use of all Microsoft Office applications and internal tools is required.
• Familiarity with Microsoft Dynamics.
• Proficient knowledge of medical justification, authorizations, billing, and appeals.
• Ability to manage, sort, and assess large data reports to summarize requested analytics. 
• Extensive knowledge of health care claims and basic regulatory billing requirements.
• Basic knowledge of CPT and ICD-10-CM coding.
• Basic knowledge of claim-by-claim medical appeals processing.

Requisition ID: 616807

Minimum Salary: $39832 

Maximum Salary: $67704 

The anticipated compensation listed above and the value of core and optional employee benefits offered by Boston Scientific (BSC) – see www.bscbenefitsconnect.com—will vary based on actual location of the position and other pertinent factors considered in determining actual compensation for the role. Compensation will be commensurate with demonstrable level of experience and training, pertinent education including licensure and certifications, among other relevant business or organizational needs. At BSC, it is not typical for an individual to be hired near the bottom or top of the anticipated salary range listed above.

Compensation for non-exempt (hourly), non-sales roles may also include variable compensation from time to time (e.g., any overtime and shift differential) and annual bonus target (subject to plan eligibility and other requirements).

Compensation for exempt, non-sales roles may also include variable compensation, i.e., annual bonus target and long-term incentives (subject to plan eligibility and other requirements).

For MA positions: It is unlawful to require or administer a lie detector test for employment. Violators are subject to criminal penalties and civil liability.

As a leader in medical science for more than 40 years, we are committed to solving the challenges that matter most – united by a deep caring for human life. Our mission to advance science for life is about transforming lives through innovative medical solutions that improve patient lives, create value for our customers, and support our employees and the communities in which we operate. Now more than ever, we have a responsibility to apply those values to everything we do – as a global business and as a global corporate citizen.

So, choosing a career with Boston Scientific (NYSE: BSX) isn’t just business, it’s personal. And if you’re a natural problem-solver with the imagination, determination, and spirit to make a meaningful difference to people worldwide, we encourage you to apply and look forward to connecting with you!

At Boston Scientific, we recognize that nurturing a diverse and inclusive workplace helps us be more innovative and it is important in our work of advancing science for life and improving patient health. That is why we stand for inclusion, equality, and opportunity for all. By embracing the richness of our unique backgrounds and perspectives, we create a better, more rewarding place for our employees to work and reflect the patients, customers, and communities we serve. 

Boston Scientific Corporation has been and will continue to be an equal opportunity employer. To ensure full implementation of its equal employment policy, the Company will continue to take steps to assure that recruitment, hiring, assignment, promotion, compensation, and all other personnel decisions are made and administered without regard to race, religion, color, national origin, citizenship, sex, sexual orientation, gender identity, gender expression, veteran status, age, mental or physical disability, genetic information or any other protected class.

Please be advised that certain US based positions, including without limitation field sales and service positions that call on hospitals and/or health care centers, require acceptable proof of COVID-19 vaccination status.  Candidates will be notified during the interview and selection process if the role(s) for which they have applied require proof of vaccination as a condition of employment.  Boston Scientific continues to evaluate its policies and protocols regarding the COVID-19 vaccine and will comply with all applicable state and federal law and healthcare credentialing requirements.   As employees of the Company, you will be expected to meet the ongoing requirements for your roles, including any new requirements, should the Company’s policies or protocols change with regard to COVID-19 vaccination.