Medical Economics Analyst – Payment Integrity

This is a fully remote position, open to applicants in New Mexico.

📋 Description

• The Payment Integrity Medical Economics Analyst is essential in pinpointing, measuring, and verifying opportunities for medical cost savings through a collaborative partnership with the Payment Integrity team.

• This position merges advanced analytics, claims validation, and financial expertise to guarantee payment accuracy, the integrity of savings initiatives, and alignment with total cost of care (TCOC) goals.

• The individual will utilize enterprise data assets, encompassing claims and provider data, to generate actionable insights, validate recoveries, and aid in pre- and post-pay integrity initiatives.

• Collaborate closely with Payment Integrity, Operations, and vendor partners (e.g., Cotiviti, Optum) to facilitate pre-pay and post-pay initiatives.

• Examine claims data to uncover patterns of overpayment, billing irregularities, and coding errors.

• Assist in the development and enhancement of rules, algorithms, and audit strategies to boost payment precision.

• Convert operational PI activities into quantifiable financial outcomes linked to TCOC.

• Confirm identified savings opportunities through thorough claims-level analysis and audit reviews.

• Create and uphold methodologies to quantify gross and net savings (pre-pay edits, post-pay recoveries, avoidance).

• Conduct before/after and control group analyses to ensure the reliability of savings estimates.

• Collaborate with finance to synchronize validated savings with the general ledger and financial reporting.

• Extract, transform, and analyze extensive healthcare datasets using SQL, SAS, or comparable tools.

• Operate within enterprise data warehouse environments to construct repeatable datasets and analytic pipelines.

• Design dashboards and reporting tools to track payment integrity performance and trends.

• Facilitate the integration of external/vendor outputs into internal analytics frameworks.

• Generate clear and concise reports on payment integrity performance, savings, and emerging opportunities.

• Develop executive-ready summaries that emphasize key drivers, risks, and recommended actions.

• Support continuous monitoring of initiative performance and the identification of new opportunities.

• Create pre-payment edit contribution invoices for Self-Funded accounts.

⛳️ Requirements

• Bachelor’s degree in Actuarial Science, Economics, Finance, Data Analytics, Healthcare Administration, or a related field (or equivalent experience).

• 2–5+ years of experience in healthcare analytics, medical economics, or payment integrity.

• Strong technical proficiency in SQL and/or SAS (required).

• Experience in querying large relational databases.

• Familiarity with claims data and reimbursement methodologies (fee schedules, IPPS, OPPS).

• Proven ability to perform financial and statistical analysis on large datasets.

• Excellent problem-solving capabilities with a keen attention to detail and data accuracy.

🏝️ Benefits

• Medical

• Dental

• Vision

• Short-term and long-term disability

• Group term life insurance

• Optional voluntary benefits

• Wellness program