Payment Integrity Analyst

spectrumhealth; Grand Rapids (MI); On-site; USD 55,000 - 75,000; Full time

Benefits offered by this job

Comprehensive benefits

On-demand pay

Discounts program

Retirement plan

ID protection

Job summary

Corewell Health in Grand Rapids seeks a Payment Integrity Analyst to help prevent overpayments by vendors and internal teams. You will apply root cause analysis and coordinate with vendors to improve claims accuracy.

The role supports implementation of prevention solutions, reviews filings for stop loss eligibility, and collaborates across departments to ensure policy compliance and effective controls.

Qualifications

• Associate's Degree or equivalent preferably in a health or business related degree.
• 2 years of health plan operations experience including end-to-end claims processes.
• Experience with root cause analysis and coding credentials preferred.

Responsibilities

• Coordinate with vendors to review findings and improve claims payment accuracy.
• Manage conflicts between providers and internal departments related to payment integrity.
• Analyze leakage and prevention results to enhance solution effectiveness.
• Oversee vendor contracts, invoicing controls, and reconciliations.
• Review filings for stop loss eligibility and compliance with policy requirements.

Skills

Root cause analysis

Claims operations

Vendor coordination

Interdepartmental collaboration

Education

Associate's degree in health or business

Bachelor's degree preferred

Tools

CRT coder (AAPC)

CRT coding specialist (AHIMA)

CRT-Physician-based CCS-P (AHIMA)

CRT RHIA/RHIT (AHIMA/AAPC)

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.

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 o