Overpayment Prevention & Claims Integrity Analyst

Spectrum Health; Grand Rapids (MI); On-site; USD 65,000 - 90,000; Full time

Job summary

Corewell Health is seeking a Payment Integrity professional to support Priority Health in preventing overpayments and improving claim accuracy. You will apply root cause analysis to develop prevention solutions and assist implementation with vendors and internal teams.

The role involves coordinating across departments to ensure proper invoicing controls, stop loss eligibility reviews, and alignment with policy requirements.

Qualifications

• Health plan operations experience including end-to-end claims processes.
• Experience with root cause analysis.
• Professional coding certifications preferred upon hire.

Responsibilities

• Coordinate with vendors to review findings and identify methods to increase claims payment accuracy.
• Analyze leakage and prevention monitoring to identify inefficiencies and improve solutions.
• Prepare check requests for vendor payments and manage controls for invoicing and adjustments.
• Ensure submissions meet stop loss policy requirements and review stop loss eligibility.

Education

Associate's Degree or equivalent

Bachelor's Degree (preferred)

Job description

Corewell Health is seeking a Payment Integrity professional to support Priority Health in preventing overpayments and improving claim accuracy. You will apply root cause analysis to develop prevention solutions and assist implementation with vendors and internal teams.

The role involves coordinating across departments to ensure proper invoicing controls, stop loss eligibility reviews, and alignment with policy requirements.