Payment Integrity Analyst

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

📋 Description

• Evaluate submitted NEMT claims for fraud, waste, abuse, billing inconsistencies, duplicate billing, overpayments, and other payment integrity issues.

• Assess claims, trip documentation, authorizations, provider records, contracts, and supplementary documentation to establish claim validity.

• Advise on claim approval, denial, adjustment, or recovery based on investigations and established guidelines.

• Accurately document claim evaluations, findings, and recommendations in specified systems.

• Identify trends, patterns, and anomalies that suggest improper billing or potential fraudulent behavior.

• Forward relevant cases to the Special Investigations Unit (SIU).

• Ensure claim decisions adhere to contractual obligations, client requirements, company policies, and federal and state regulations.

• Partner with Claims Operations, SIU, Compliance, Provider Relations, and other internal departments.

• Contribute to the enhancement of payment integrity processes, controls, and audit methodologies.

• Uphold productivity, quality, and turnaround-time standards.

• Generate reports and convey findings to leadership.

• Maintain confidentiality and adhere to HIPAA and privacy and security regulations.

• Engage in continuous training related to payment integrity, fraud prevention, and NEMT operations.

• Execute additional responsibilities as assigned.

⛳️ Requirements

• High school diploma is mandatory.

• A Bachelor's degree from an accredited college or university is preferred.

• Four (4) years of relevant experience in claims analysis, Payment Integrity, SIU, or FWA investigations.

• Strong analytical and investigative abilities with outstanding attention to detail.

• Familiarity with payment integrity principles and techniques for detecting fraud, waste, and abuse.

• Understanding of NEMT claims processing, provider billing practices, and supporting trip documentation.

• Capacity to analyze extensive volumes of claim and operational data.

• Ability to demonstrate sound judgment and provide well-supported claim recommendations.

• Strong written and verbal communication skills.

• Proficiency in Microsoft Office Suite, especially Excel.

• Ability to handle multiple priorities and meet deadlines.

• Proven integrity, professionalism, and dedication to confidentiality.

• Experience with NEMT claims and operations is preferred.

• Experience with Medicaid managed care programs is a plus.

• Knowledge of NEMT provider billing practices, trip documentation requirements, and authorization processes is preferred.

• Experience utilizing claims management systems and data analysis tools is preferred.

• Professional certification related to fraud examination, investigations, auditing, or payment integrity is preferred.

🏝️ Benefits

• Medical, Dental, and Vision insurance.

• Employer Paid Basic Life Insurance and AD&D.

• Voluntary Life Insurance (Employee/Spouse/Child).

• Health Care and Dependent Care Flexible Spending Accounts.

• Pre-Tax and Post-Tax Commuter and Parking Benefits.

• 401(k) Retirement Savings Plan with Company Match.

• Paid Time Off.

• Paid Parental Leave.

• Short-Term and Long-Term Disability.

• Tuition Reimbursement.

• Employee Discounts (retail, hotel, food, restaurants, car rental and much more!).