Payment Integrity Analyst II

At our company, our mission starts with our people. Guided by our HEART values of Humility, Excellence, Accountability, Respect, and Trust, we strive to create a workplace where teammates feel valued, supported, and empowered to do their best work every day. As a Payment Integrity Analyst II, you’ll help improve claims-payment accuracy, support cost-reduction initiatives, and ensure compliance with payment policies and regulations. You’ll analyze data, identify payment trends, collaborate with internal teams and vendors, and develop solutions that prevent and recover overpayments.

Job Duties & Responsibilities
• Reviews claim payments for accuracy through prepayment edits, audits, contract-compliance reviews, and post-payment payment-integrity solutions
• Supports overpayment identification, recovery, remediation, and prevention activities
• Analyzes overpayment, refund, and claims data to identify trends, savings opportunities, and potential payment-integrity initiatives
• Develops and supports strategies that recover overpayments and establish controls to prevent future payment errors
• Tracks, analyzes, and ensures accurate and timely processing of payment-integrity invoices
• Supports retrospective data mining and prospective cost-avoidance initiatives
• Serves as a resource and mentor for team members
• Assists with customization of claims-payment algorithms and edits
• Supports vendor implementations, configurations, quality assurance activities, and ongoing oversight
• Coordinates with vendors and internal teams to maintain payment-integrity solutions and improve claims-payment accuracy
• Collaborates with content, technical, and data teams to develop, adjust, validate, and maintain payment-policy edits
• Responds to escalated internal and external inquiries, provider disputes, and payment-integrity research requests
• Monitors vendor file submissions, invoicing, quality metrics, and performance against established expectations
• Identifies payment-integrity issues, evaluates evidence and data, and recommends technical or process improvements
• Reviews health care policies and coding guidance to identify billing and coding rules appropriate for claims-edit development
• Translates policy requirements into specifications for software coding edits and validates that edits function as intended

Qualifications
• High school diploma required
• Bachelor’s degree preferred
• Three or more years of health care data experience required
• Two or more years of experience participating in health care payer programs, including Medicare, Medicaid, or commercial plans, required
• Two or more years of claims-editing experience with health care payers or claims-editing software vendors required
• Project implementation experience required
• Certified Coding Specialist, Certified Coding Specialist Physician-Based, or Registered Health Information Administrator certification preferred