Payment Integrity Analyst

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

Job summary

Priority Health is seeking a qualified analyst to apply analytical and technical skills to prevent overpayments identified by vendors and other sources. You will leverage root cause analysis to develop and implement overpayment prevention solutions and assist with stop loss analysis within Priority Health.

The role collaborates with vendors and internal teams to enhance payment integrity and ensure alignment with policy requirements.

Qualifications

• Associate's Degree or equivalent in health or business.
• 2 years health plan operations experience including end-to-end claims.
• Experience with root cause analysis.
• Professional coding credentials preferred on hire (CPC/CCS/CCS-P/RHIA/RHIT).

Responsibilities

• Coordinate with vendors to review findings and identify methods to increase claims payment accuracy.
• Manage and resolve conflicting views from providers and internal departments.
• Analyze leakage and prevention results to improve solution effectiveness.
• Coordinate vendor contracts and manage invoicing, validation and adjustments.
• Collaborate with other departments on cross‑functional projects.
• Review filings to ensure eligibility aligns with stop loss policy.
• Verify stop loss coverage and plan eligibility requirements (FMLA, MLOA, COBRA).

Skills

Root cause analysis

Vendor coordination

Problem solving

Education

Associate's Degree

Bachelor's Degree

Job description

Job Summary

Applies analytical and technical skills and assist in development of solutions to prevent overpayments identified by vendors and through other means. Applies root cause analysis findings to assist with developing overpayment prevention solutions and assist implementation efforts within Priority Health. Works with vendors and other key business areas to address effectiveness of overpayment prevention solutions and identify potential solution enhancements as necessary. Also may be responsible for stop loss analysis.

Job Summary

Applies analytical and technical skills and assist in development of solutions to prevent overpayments identified by vendors and through other means. Applies root cause analysis findings to assist with developing overpayment prevention solutions and assist implementation efforts within Priority Health. Works with vendors and other key business areas to address effectiveness of overpayment prevention solutions and identify potential solution enhancements as necessary. Also may be responsible for stop loss analysis.

Essential Functions

• Coordinate with vendors to review findings and identify methods to increase claims payment accuracy and integrity.
• Ability to manage and resolve conflicting points of view from providers and internal departments (includes appeals to health plan for Payment Integrity initiatives).
• Analyze results of ongoing leakage and prevention monitoring to identify inefficiencies and improve solution effectiveness.
• Coordinate and support activities related to vendor contracts. Manage proper controls for vendor invoicing, validation, reconciliations and adjustments. Prepare check requests for vendor payments.
• Coordinate with other departments as needed to accomplish cross–departmental projects and/or goals.
• Analyze and review initial, subsequent and or final filings to ensure submissions received are covered and eligibility requirements are satisfied per the groups stop loss policy (SPD, stop loss policy, fee disclosure).
• Examine claims for stop loss eligibility including verifying stop loss coverage, eligibility (knowledge of plan eligibility requirements including FMLA, MLOA, COBRA).

Qualifications

Required

• Associate's Degree or equivalent preferably in a health or business related degree
• 2 years of relevant experience Health plan operations experience to include end to end claims operations and processes.
• Experience with root cause analysis.
• CRT-Professional Coder - AAPC American Academy of Professional Coders Upon Hire preferred Or
• CRT-Coding Specialist (CCS) - AHIMA American Health Information Management Association Upon Hire preferred Or
• CRT-Coding Specialist, Certified-Physician Based (CCS-P) - AHIMA American Health Information Management Association Upon Hire preferred Or
• CRT-Registered Health Information Administrator (RHIA) - AHIMA American Health Information Management Association Upon Hire preferred Or
• CRT-Registered Health Information Technician (RHIT) - AAPC American Academy of Professional Coders Upon Hire preferred Or

Preferred

• Bachelor's Degree preferably in a health or business related degree

About Corewell Health

As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.

How Corewell Health cares for you

• Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
• On-demand pay program powered by Payactiv
• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
• Optional identity theft protection, home and auto insurance
• Traditional and Roth retirement options with service contribution and match savings
• Eligibility for benefits is determined by employment type and status

Primary Location

SITE - Priority Health - 1239 E Beltline Ave NE - Grand Rapids

Department Name

Payment Integrity Planning and Implementation - PH Managed Benefits

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

40

Hours of Work

8a-5p

Days Worked

M-F

Weekend Frequency

N/A

Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.