Payment Integrity Analyst - Remote

Payment Integrity Analyst Remote, United States About the Position You are a person who loves to identify discrepancies, prevent overpayments, and ensure adherence to regulatory, contractual, and coding guidelines. We need someone with expertise in medical coding, reimbursement methodologies, and healthcare policy who can develop, implement, and maintain claims editing rules and audit processes. In this role you ensure the accuracy and compliance of healthcare claim payments across commercial, Medicare, and Medicaid lines of business. Key Responsibilities Lead complex claim audits and investigations involving high‑risk or high‑value claims Design, develop, and maintain advanced claims editing rules and logic Translate complex regulatory and reimbursement policies into system specifications Oversee testing, validation, and implementation of editing rules Conduct root‑cause analysis and recommend systemic solutions Monitor CMS, OIG, and regulatory updates; ensure organizational compliance Act as SME for coding, billing, and payment integrity methodologies Mentor junior analysts and provide technical guidance Collaborate with IT, policy, and leadership teams on strategic initiatives Support benefit configuration and optimization in platforms like TriZetto Facets Present findings, insights, and recommendations to leadership Claims Review & Audit Perform pre‑pay and post‑pay reviews of medical claims for accuracy, medical necessity, and compliance Identify billing errors including duplicate claims, unbundling, upcoding, and modifier misuse Ensure alignment with Tricare and VA Policy, CMS, state regulations, and payer‑specific policies Payment Integrity & Recovery Detect and quantify overpayments and support recovery efforts Analyze claim patterns to identify systemic issues and cost‑saving opportunities Partner with recovery vendors and internal teams to resolve discrepancies Policy & Rule Development Interpret healthcare policies (Tricare/VA Policy, CMS manuals, NCCI edits, LCDs/NCDs, fee schedules) Translate regulatory and coding guidance into automated claims editing logic Define rule specifications, decision pathways, and acceptance criteria Support configuration and optimization of claims editing platforms (e.g., Optum CES, TriZetto Facets) Data Analysis & Validation Analyze large datasets to identify trends, anomalies, and root causes of payment errors Develop SQL queries and reports to support audit findings and rule validation Perform testing and validation of editing rules and system configurations Regulatory Monitoring & Compliance Monitor updates from Tricare and VA Policy, CMS, OIG, and industry sources for regulatory changes Maintain compliance with federal and state healthcare laws and reimbursement policies Support development and maintenance of medical policies and procedures Collaboration & Communication Work cross‑functionally with claims, IT, clinical, compliance, and client policy teams Serve as a subject matter expert (SME) on coding, billing, and payment integrity issues Communicate findings, policy interpretations, and recommendations to stakeholders Minimum Requirements Associate's or Bachelor's degree in Health Administration, Public Health, Business, or related field (or equivalent experience) 5+ years of experience in healthcare claims, payment integrity, auditing, or revenue cycle Advanced expertise in coding systems, reimbursement methodologies, and CMS regulations Strong experience with claims editing platforms (e.g., Optum CES) Advanced SQL and data analysis skills Demonstrated experience in rule development and system configuration Experience with Tricare and Veterans Administration, Medicare, Medicaid, and/or commercial reimbursement methodologies Hands‑on experience with claims adjudication and editing systems Strong knowledge of: CPT, HCPCS, ICD‑10 coding systems NCCI edits and CMS guidelines Proficiency in: SQL and data analysis Excel (pivot tables, VLOOKUP, data manipulation) Experience with EDI transactions, CMS‑1500, and claims workflows One or more of the following certifications: CPC (Certified Professional Coder) CCS / CCS‑P (Certified Coding Specialist)

RHIT / RHIA

Strategic thinking Leadership and mentorship Advanced analytical and technical skills Deep regulatory and policy expertise Strong decision‑making and problem‑solving ability About the Benefits Health Insurance Fully Paid Life Insurance Fully Paid Short‑ & Long‑Term Disability Paid Vacation Paid Sick Leave Paid Holidays Professional Development and Tuition Assistance Program 401(k) Program with Employer Match Security Requirements U.S. Citizenship or naturalized citizenship is required for this position. All work must be completed in the continental United States, Alaska, or Hawaii. Work Schedule Monday – Friday, 8:00 a.m. – 5:00 p.m. CST Compensation Range $118,000 per year Position Type Full Time #J-18808-Ljbffr Signature Performance