Payment Integrity Analyst

Health One Alliance, LLC; Dalton (GA); On-site; USD 60,000 - 80,000; Full time

Benefits offered by this job

401K (4% Match, Immediate Vesting)

Medical Insurance

Paid Time Off

Dental Insurance

Vision Insurance

Life & AD&D Insurance

Short Term Disability

Long Term Disability

Accident insurance

Flexible Spending Account

Health & Wellness Program

Health Savings Account

Critical Illness Insurance

Employee Assistance Program

Pet Insurance

Job summary

Health One Alliance, LLC is seeking a Payment Integrity Analyst in Dalton, GA. The role involves reviewing healthcare claims to detect errors or fraud while ensuring compliance with CMS regulations.

Key responsibilities include auditing claims, analyzing data trends, collaborating with internal teams, and preparing reports. Candidates should have experience in claims processing and medical billing, as well as strong analytical skills and knowledge of medical coding.

The position offers competitive benefits including health insurance, paid time off, and a 401K plan.

Qualifications

• Minimum of three years experience in claims processing is required, including Professional and Institutional processing.
• Knowledge of ICD-10, CPT4, DRG, and HCPCS codes preferred.
• Experience in medical billing and coding required if no claims processing experience.

Responsibilities

• Review and audit healthcare claims to identify payment errors and fraud.
• Ensure compliance with regulations and health plan policies.
• Analyze medical records and claims data to validate accuracy.

Skills

Data analysis

Medical coding (CPT/ICD-10)

Auditing skills

Claims processing

SQL reporting

Education

High School Diploma or GED

Associates or Bachelor's degree

Tools

Microsoft Word

Microsoft Excel

Job description

JOB PURPOSE

A Payment Integrity Analyst reviews healthcare claims, payments, and billing to find errors, fraud, waste, or abuse, ensuring compliance with rules (like CMS) and policies, using strong data analysis, medical coding (CPT/ICD-10), and auditing skills to prevent financial loss and improve accuracy, often working with vendors and internal teams. Key duties include auditing claims, investigating anomalies, analyzing data for trends, collaborating on billing edits, and preparing reports to support cost containment for health plans.

ESSENTIAL JOB DUTIES

• Review and audit healthcare claims to identify payment errors, overpayments, underpayments, fraud, waste, and abuse (FWA).
• Ensure compliance with CMS regulations, state and federal guidelines, health plan policies, and provider contract terms.
• Analyze medical records, itemized bills, and claim data to validate coding accuracy and medical necessity.
• Apply CPT, HCPCS, ICD-10-CM/PCS, and modifier guidelines to validate correct reimbursement.
• Identify trends, patterns, and anomalies through data analysis to support cost containment initiatives.
• Perform detailed reviews of high-dollar and complex claims to ensure payment accuracy, contract compliance, and medical necessity prior to or after payment.
• Investigate potential payment integrity issues, including duplicate payments, unbundling, upcoding, and incorrect modifiers.
• Collaborate with internal teams (Claims, Configuration, Provider Relations, Compliance, Legal, Analytics, Medical Management) to resolve findings.
• Work closely with internal and external vendors to review audit findings, validate recoveries, and implement corrective actions.
• Prepare detailed audit documentation, summaries, and reports for leadership, compliance, and recovery tracking.
• Present audit findings and recommendations to stakeholders in a clear and professional manner.
• Monitor and track audit outcomes, recoveries, and key performance indicators (KPIs).
• Participate in continuous process improvement initiatives to enhance payment accuracy and efficiency.
• Stay current with regulatory updates, coding changes, CMS guidance, and industry best practices.
• Support internal and external audits, regulatory requests, and compliance reviews as needed.
• Maintain regular and predictable attendance.
• Consistently demonstrate compliance with HIPAA regulations, professional conduct, and ethical practice.
• Work to encourage and promote company culture throughout the organization.
• Other duties as may be assigned.

QUALIFICATIONS

• High School Diploma or GED required.
• Associates or Bachelor's degree preferred.
• A minimum of three years’ experience in claims processing required, must include Professional and Institutional processing; previous experience in medical billing and coding required if no claims processing experience.
• Knowledge of ICD-10, CPT4, DRG, HCPCS codes, medical terminology, EDI and HIPAA protocols preferred.
• Knowledge of UB and HCFA 1500 forms.
• Experience with Word and Excel.
• Experience with SQL reporting is preferred.

PHYSICAL REQUIREMENTS

Prolonged periods of sitting at a desk and working on a computer. Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day responsibilities. Must be able to drive a vehicle and daytime/overnight travel as required.

BENEFITS

• 401K (4% Match, Immediate Vesting)
• Accident insurance
• Competitive salary
• Critical Illness Insurance
• Dental Insurance
• Employee Assistance Program
• Flexible Spending Account
• Health & Wellness Program
• Health Savings Account
• Life & AD&D Insurance
• Long Term Disability
• Medical Insurance
• Paid Time Off
• Pet Insurance
• Short Term Disability
• Vision Insurance

EQUAL OPPORTUNITY EMPLOYER

HealthOne is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, disability, sex, age, ethnic or national origin, marital status, sexual orientation, gender identity or presentation, pregnancy, genetics, veteran status, or any other status protected by state or federal law.