Payment Integrity Analyst
$65k - $92kTalentLNX
- Payment Integrity AnalystClinical Audit & Revenue IntegrityRemoteJune 30, 2026$65,000 - $92,000 / yearFull TimeRemoteApplication ends: **August 31, 2026**Apply Now### Job Description**Location:** Remote (US-based)We are seeking a **Payment Integrity Analyst** to identify and document overpayment recovery opportunities across payer claims for a health plan. This position is a full-time, direct hire opportunity available on a fully remote basis within the US.This role suits an analyst who is equally comfortable in a SQL editor and a CMS policy memo and who takes genuine satisfaction in finding the specific claims configuration behind a large recovery opportunity. You will work independently as an individual contributor from a remote home-based office, building and refining recovery concepts, stress-testing your own logic against payer adjudication behavior, and writing findings that a medical director will accept on the merits. A background in payer SIU, claims audit, or health plan analytics is ideal, and remote flexibility plus direct exposure to a broad cross-section of payer claims makes this a strong platform for analysts who want to grow their payment integrity expertise quickly.**Responsibilities:*** Query claims data warehouses to identify billing patterns violating payer medical policy and CMS coding conventions.* Identify overpayment patterns: unbundling, upcoding, modifier misuse, place-of-service manipulation, and duplicates.* Apply CPT, HCPCS, ICD-10, and **DRG** methodology to validate coding logic and confirm payable errors.* Cite CMS policies, LCDs, CCI edits, and payer guidelines supporting recovery concepts.* Quantify gross and net recovery per finding, adjusting for denial rates and appeal risk.* Produce structured documentation with rationale, citations, and recovery calculations.* Escalate complex determinations to clinical review for medical necessity and diagnosis-linkage validation.* Track findings through QA, incorporate feedback, and maintain version-controlled documentation for appeals defense.* Support appeals with source data pulls, policy references, and rebuttals to provider objections.**Qualifications:*** Demonstrate 3+ years payment integrity, claims audit, special investigations experience developing recovery concepts* Master complex SQL: joins, window functions, aggregations, subqueries across Snowflake, Teradata, SQL Server, Databricks* Master CPT, HCPCS Level II, ICD-10-CM/PCS, CCI edits, modifier rules, DRG grouper methodology independently* Apply CMS National/Local Coverage Determinations, NCCI manuals, payer medical policies supporting payment integrity concepts* Build Excel workbooks using pivot tables, VLOOKUP/XLOOKUP, INDEX-MATCH, conditional logic, data validation for recovery* Produce precise, policy-grounded narratives at technical clarity satisfying medical directors and client compliance teams**Schedule:**Fully remote within the US. Standard business hours, Monday through Friday.**Salary Range:** The salary range for this position is approximately $65,000 – $92,000 annually ($31.25 – $44.23 per hour), based on experience and qualifications.**Interview Process:*** Selected candidates will participate in a multi-step interview process, including an initial screening with TalentLNX followed by interviews with department leadership.
- J-18808-Ljbffr TalentLNX
Vacancy posted 3 days ago
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