Payment Integrity Analyst

This is a fully remote position, open to applicants in United States.

📋 Description

• Examine possible inaccuracies in payments utilizing expertise in Medicare Advantage adjudication and reimbursement.

• Analyze claims populations identified through SQL queries, differentiating between payment discrepancies, legitimate exceptions, data issues, and accurately adjudicated claims.

• Conduct research on CMS/NCCI and other coding guidelines, provider contract stipulations, benefit documents, internal payment policies, and configuration requirements.

• Determine effective dates, relevance, and unresolved source conflicts.

• Evaluate claim and line details, payment components, adjustments, reversals, and pertinent claim history.

• Execute SQL queries independently, adjusting dates, filters, and claim selections as necessary.

• Look for evidence that may refute suspected issues, including comparison claims that were correctly paid and alternative explanations.

• Record sources, validation procedures, exclusions, payment impacts, and unresolved inquiries for reproducible review.

• Utilize approved AI tools for research, query interpretation, and documentation while ensuring verification of outputs.

• Review and audit outputs from audit tools, pinpoint false positives, and enhance rules.

• Prepare findings for review and assist in recovery evaluation, operational resolutions, and Compliance/Legal examinations.

• Participate in recurring audits, monitor validated issues, and propose enhancements to investigation and testing protocols.

⛳️ Requirements

• 3–5 years of relevant experience in payment integrity, reimbursement analysis, claims auditing, complex claims research, claims examination, or related roles, including direct experience with Medicare Advantage.

• Strong practical understanding of Medicare Advantage claims adjudication and reimbursement processes.

• Familiarity with benefit provisions, provider contracts, payment policies, and how configurations impact payment outcomes.

• Capability to investigate payment discrepancies, evaluate competing explanations, identify exceptions, and differentiate between suspected issues and supported findings.

• Ability to carry out defined investigations independently, identify missing information, and escalate complex or unresolved issues.

• Practical proficiency in SQL and ability to navigate extensive relational database environments.

• Strong skills in Excel, including experience in reviewing, filtering, comparing, and reconciling claims-level datasets.

• Hands-on experience with AI tools in analytical, research, or claims-related activities, demonstrating sound judgment in verification and data management.

• Excellent written and verbal communication skills.

• High attention to detail and the capability to manage multiple investigations with organized, traceable documentation.

• Experience with Medicare Advantage claims and reimbursement processes.

• Coding or reimbursement credentials are beneficial but not mandatory.

🏝️ Benefits

• Competitive base salary.

• Equity opportunities.

• Performance-based bonus program.

• 401k matching.

• Regular compensation reviews.

• Comprehensive medical, dental, and vision coverage.

• No-Meeting Fridays.

• Monthly company holidays.

• Mental health resources.

• Generous flexible time-off policy.

• Remote-first culture.

• Learning programs.

• Mentorship.

• Professional development funding.

• Regular performance feedback and reviews.

• Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities.

• Reimbursement for office setup expenses.

• Monthly cell phone & internet stipend.

• Collaboration with global teams.

• Paid parental leave for all new parents.