Payment Integrity Analyst

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

📋 Description

• Oversee the inventory of overpayments

• Evaluate claims, coding, contracts, and clinical documentation to pinpoint erroneous payments

• Verify audit results

• Formulate recommendations and action plans for remediation

• Utilize data analytics, auditing methodologies, and regulatory knowledge to uncover reimbursement discrepancies

• Assist in the recovery processes for overpayments

• Reduce the risk of future payment integrity issues

• Collaborate with clinical, legal, SIU/FWA, provider relations, and IT departments

• Analyze trends of improper spending

• Implement enduring solutions

• Ensure audit-ready documentation is maintained

• Contribute to enhancements of business rules

• Facilitate operational improvements that bolster payment accuracy and create incremental savings opportunities throughout the claims lifecycle

• Incorporate IEHP’s Quality Program objectives, including HEDIS, CAHPS, and NCQA Accreditation

⛳️ Requirements

• At least three (3) years of experience in healthcare claims processing, billing, and/or auditing functions is required

• Familiarity with contract interpretation and Division of Financial Responsibility (DOFR)

• Experience with data analysis and queries

• Bachelor’s degree in healthcare, finance, or a related discipline from an accredited institution is required

• Alternatively, a minimum of four (4) years of additional relevant work experience is necessary; this experience is supplementary to the minimum years stated in the Experience Requirements above

• Certification in RHIA, RHIT, CCS, CPC, CIC, or a similar credential is preferred

• Strong grasp of medical coding (CPT, ICD-10, HCPCS) and health insurance contracts

• Comprehensive understanding of the complete claims lifecycle, including share of cost and coordination of benefits

• In-depth knowledge of Medicaid/Medi-Cal or Medicare regulatory frameworks

• Solid understanding of payment integrity principles, including pre-pay and post-pay audit types, DRG validation, coordination of benefits, and related concepts

• Intermediate proficiency in SQL and Microsoft Office Suite (Excel, Access) is required

• Proven ability to make independent decisions regarding claim coding and adjudication

• Strong analytical, problem-solving, and trend analysis capabilities

• Ability to convert analytical insights into operational recommendations

• Excellent organizational and planning skills

• Proficient in effective communication with both internal stakeholders and external parties

• Capability to independently prioritize caseloads based on impact and deadlines

🏝️ Benefits

• Competitive salary

• State-of-the-art fitness center on-site

• Medical Insurance inclusive of Dental and Vision coverage

• Options for Life, short-term, and long-term disability insurance

• Opportunities for career advancement and professional development

• Wellness initiatives that support a healthy work-life balance

• Flexible Spending Account for Health Care/Childcare

• CalPERS retirement plan

• 457(b) plan with a contribution match

• Paid life insurance for employees

• Pet care insurance