Payment Integrity Analyst II

Payment Integrity Analyst II

This remote role focuses on ensuring healthcare claims are reviewed accurately, consistently, and in accordance with applicable policies and industry standards. You will analyze pre- and post-payment claims, audits, and appeals using clinical judgment and healthcare reimbursement expertise. The position combines clinical knowledge, claims analysis, coding awareness, and data-driven problem solving. You will help identify payment accuracy opportunities while supporting compliance with CMS and commercial payer requirements. The role involves working across multiple priorities and communicating findings clearly to internal teams, clients, and senior stakeholders. Success requires strong attention to detail, sound judgment, and the ability to translate complex information into actionable conclusions. It is an opportunity to contribute directly to healthcare payment integrity within a collaborative, fast-paced, and evolving environment.

Accountabilities:

• Review, analyze, and complete pre- and post-payment claim audits and appeals in accordance with client policies, CMS guidelines, and healthcare industry standards.
• Apply clinical judgment to evaluate documentation and determine the appropriateness and accuracy of claims.
• Interpret and apply payer policies and regulatory requirements across areas such as itemized bills, DRG reviews, and specialty audits.
• Use relevant systems, tools, and resources to conduct thorough and timely audits, appeals, and payment integrity reviews.
• Analyze healthcare claims, reimbursement information, and supporting documentation to identify discrepancies and potential payment issues.
• Communicate audit findings and conclusions clearly and professionally in both written and verbal formats.
• Manage multiple projects and priorities while meeting established deadlines and quality expectations.
• Participate in clinical team meetings, company meetings, training sessions, educational opportunities, and other relevant activities.
• Collaborate effectively with internal stakeholders and interact professionally with clients and senior-level audiences when required.
• Contribute analytical insights and actionable recommendations that support strategic payment integrity initiatives.
• Perform additional responsibilities as assigned.

Requirements:

• Maintain an active LPN, LVN, and/or RN license.
• Bring at least 1 year of relevant professional experience or an equivalent combination of education and experience.
• Have at least 1 year of experience in healthcare revenue cycle and 1 year of hospital bill auditing experience.
• Demonstrate strong knowledge of claims processing, ICD-10 coding, DRG validation, coordination of benefits, healthcare revenue cycles, and claims reimbursement.
• Have experience in medical bill auditing and/or clinical environments such as operating rooms, intensive care, emergency care, telemetry, medical/surgical units, obstetrics, geriatrics, or orthopedics.
• Experience with health insurance denials and appeals, payer or vendor audits, workers' compensation claims, or prospective, concurrent, and retrospective utilization review is preferred.
• A bachelor's degree in healthcare or a related field is preferred.
• Demonstrate working knowledge of CMS requirements and commercial payer policies.
• Be proficient with Microsoft Office, including Pivot Tables and database management.
• Possess strong analytical, data interpretation, modeling, and complex problem-solving abilities.
• Demonstrate excellent written and verbal communication skills, interpersonal effectiveness, adaptability, and a results-oriented mindset.
• Be comfortable managing multiple projects, setting priorities, and working within committed timelines.
• Show exceptional attention to detail and the ability to perform effectively in a fast-paced, dynamic environment.
• Be capable of working independently while collaborating effectively with broader clinical and business teams.

Benefits:

• Salary range: $66,941–$101,258, with compensation determined by factors including location, experience, qualifications, skills, internal equity, and market conditions.
• Remote work arrangement.
• Medical insurance, including HDHP options with pharmacy coverage.
• Dental and vision insurance.
• Health Savings Account (HSA) and Flexible Spending Account (FSA) options.
• Long-term disability and life insurance.
• Accident and critical illness insurance.
• 401(k) and Roth 401(k) retirement plans.
• Paid time off.
• Pre-paid legal insurance.
• Parking and transit FSA options.
• Opportunities for professional development, training, and career advancement.
• A collaborative environment focused on healthcare payment accuracy, quality, and continuous improvement.