What You'll Do

The Payment Integrity Analyst is responsible for working with various business stakeholders to define, identify and operationalize the payment integrity process. This position will be part of the operations team and will support fraud, waste & abuse initiatives for clients and the product.

• Identify and investigate new fraud, waste, abuse, and error (FWAE) concepts.
• Coordinate with client(s) and vendor(s) to identify overpayments through payment integrity initiatives and increase payment accuracy..
• Collect supporting data and analyze information to make decisions regarding the appropriateness of billing..
• Provides insight for new claim scenario creation, validation, deployment and monitoring..
• Ability to work independently and as a team member while using discretion in decision making and sound judgement in problem solving..
• Create documentation, various reports and presentations..
• Perform other duties as assigned.

Notches In Your Belt:

• BS/BA and 3 years in Health Care Insurance in an operations area to include 2 years in Claims operations and analysis experience such as root-cause analysis or 5 years of Health Care Insurance in an operations area including Claims operations.
• Thorough knowledge of medical billing codes including but not limited to CPT, ICD-10-PCS, ICD-10-CM, HCPCS, NDC, and PDPM as well as an understanding of medical terminology, and prospective payment systems including DRG, OPPS, and MIPS
• Knowledge of claims coding, regulatory rules and medical policy
• Creative thinker with an entrepreneurial spirit
• Excellent communication skills and strong ability to communicate results to a diverse audience
• Be capable of multitasking and working in a fast-paced environment
• Be flexible, dependable, and resourceful
• Have a desire to innovate and improve medical care