Payment Integrity Analytics Specialist

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

📋 Description

• Develop, maintain, and distribute dashboards, reports, and performance scorecards focused on payment integrity.

• Track and monitor metrics related to recoveries, cost avoidance, savings, inventory, and operational performance.

• Analyze claims, provider, reimbursement, and audit data to pinpoint opportunities for payment integrity and emerging trends.

• Assist in detecting fraud, waste, and abuse through thorough data analysis and reporting efforts.

• Monitor vendor performance and validate reported recoveries, savings, and contractual performance metrics.

• Create recurring reports for operational, financial, and executive levels.

• Conduct data validation, reconciliation, and quality assurance tasks.

• Support audit targeting, provider outlier analysis, and the identification of recovery opportunities.

• Generate ad hoc analyses and presentations to aid leadership decision-making.

• Collaborate with Information Technology and enterprise data teams to enhance reporting capabilities and data accessibility.

• Identify trends, risks, and opportunities, providing data-driven recommendations to leadership.

• Assist with budgeting, forecasting, and performance measurement activities related to payment integrity programs.

• Support regulatory reporting, audits, and documentation requests.

• Participate in departmental meetings and assigned projects.

• Engage in compliance and operational initiatives as necessary.

• Perform other assigned duties as needed.

• Collaborate with Payment Integrity leadership, Claims Operations, Finance, Compliance, Information Technology, and external vendors.

⛳️ Requirements

• A minimum of 3 years of experience in healthcare analytics, claims analytics, payment integrity, finance analytics, reimbursement analysis, or a closely related field is required.

• High school diploma or equivalent is essential.

• A bachelor's degree in business, finance, statistics, data analytics, healthcare administration, information systems, or a related area is preferred.

• Familiarity with healthcare claims processing and reimbursement methodologies is necessary.

• Proficiency in data analysis and reporting techniques is required.

• Strong knowledge of Microsoft Excel and reporting tools is essential.

• Understanding of statistical analysis and performance measurement concepts is important.

• Experience with SQL, Power BI, Tableau, or similar reporting platforms is preferred.

• Familiarity with Medicare, Medicaid, Commercial, and Marketplace health plan operations is preferred.

• Ability to read and understand both written and spoken English is crucial.

• Effective communication skills are required.

• Ability to meet departmental and company performance and attendance standards is essential.

• Must adhere to PacificSource privacy policies and HIPAA laws and regulations regarding confidentiality and the security of protected health information.

• Ability to stoop and bend, sit and/or stand for extended periods, perform repetitive motions, and engage in light lifting and carrying is required.

• Travel is required approximately 5% of the time.

🏝️ Benefits

• Equal opportunity employment.

• Work-from-home arrangement.

• Ergonomically configured equipment.

• Opportunities to engage in community, social justice, equity, diversity, and inclusion initiatives.