Payment Integrity Analyst

Inland Empire Health Plans; Rancho Cucamonga (CA); On-site; USD 75,000 - 95,000; Full time

Benefits offered by this job

Competitive salary

On-site fitness center

Medical Insurance with Dental and Vis

Life, short-term, and long-term-dis

Career advancement & professional dev

Wellness programs for work-life bal

Flexible Spending Account – Health/Ca

CalPERS retirement

457(b) plan with match

Employee life insurance

Pet care insurance

Job summary

Inland Empire Health Plans is seeking a Payment Integrity Analyst in Rancho Cucamonga to monitor overpayment inventories and analyze claims, coding, contracts, and clinical documentation for improper payments. You will validate audit findings and develop remediation actions while using data analytics, audit methodologies, and regulatory expertise.

The role collaborates with clinical, legal, SIU/FWA, provider relations, and IT teams to implement sustainable solutions and strengthen payment

Qualifications

• Three years of experience in healthcare claims processing, billing, and/or auditing functions.
• Experience with contract interpretation and DOFR; data analysis/queries experience.
• Bachelor’s degree in healthcare, finance, or related field required; or four additional years of relevant work experience in lieu of degree.
• Certification such as RHIA, RHIT, CCS, CPC, CIC or similar preferred.

Responsibilities

• Monitor overpayment inventory and analyze claims, coding, contracts, and clinical documentation to identify improper payments.
• Validate audit findings and develop remediation recommendations and actions.
• Collaborate with cross-functional teams including clinical, legal, SIU/FWA, provider relations, and IT to address improper spend patterns.
• Maintain audit-ready documentation and support payment integrity initiatives across the claims lifecycle.

Skills

SQL

Microsoft Office

Data analysis

Communication

Auditing

Analytical thinking

Education

Bachelor's degree in healthcare/finance or related field

Tools

Excel

Job description

What you can expect!

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to anauthentic experience!

Reporting to the Manager, Payment Integrity Operations, the Payment Integrity Analyst monitors the overpayment inventory and performs analysis of claims, coding, contracts, and clinical documentation to identify improper payments, validate audit findings, and develop remediation recommendations and actions. This position leverages data analytics, audit methodologies, and regulatory expertise to detect reimbursement inaccuracies, support overpayment recovery processes, and mitigate future risk. This role collaborates with cross-functional teams including clinical, legal, SIU/FWA, provider relations, and IT to assess patterns of improper spend and implement sustainable solutions. The role maintains audit ready documentation, contributes to business rule enhancements, and supports operational improvements that strengthen payment accuracy and incremental savings opportunities across the claims lifecycle.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• Competitive salary
• State of the art fitness center on-site
• Medical Insurance with Dental and Vision
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development
• Wellness programs that promote a healthy work-life balance
• Flexible Spending Account – Health Care/Childcare
• CalPERS retirement
• 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance

Education & Requirements

• A minimum of three (3) years of experience in a combination of healthcare claims processing, billing, and/or auditing functions required
• Experience with contract and Division of Financial Responsibility (DOFR) interpretation. Experience with data analysis/queries experience
• Bachelor’s degree in healthcare, finance, or a related field from an accredited institution required
  • In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position
  • This experience is in addition to the minimum years listed in the Experience Requirements above
• Certification in RHIA, RHIT, CCS, CPC, CIC or similar certification preferred

Key Qualifications

• Strong understanding of:
  • Medical coding (CPT, ICD-10, HCPCS) and health insurance contracts
  • The full claims lifecycle, including share of cost and coordination of benefits
  • Medicaid/Medi-Cal or Medicare regulatory frameworks
  • Payment integrity concepts (pre-pay audit, post-pay audit types, DRG validation, coordination of benefits and comparable concepts)
• Intermediate in SQL and Microsoft Office Suite (Excel, Access) required
• Demonstrated ability to make independent decisions in claim coding and adjudication
• Strong analytical, problem-solving, and trend analysis skills
• Ability to translate analytical findings into operational recommendations
• Solid organizational and planning capabilities
• Ability to communicate effectively with internal stakeholders and external parties
• Ability to independently prioritize caseloads based on impact and timelines