Payment Integrity Analyst

Jobtailor; Rancho Cucamonga (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

Jobtailor is seeking a Health Plan Claims Auditor to independently investigate data mining leads, claim errors, and overpayments. You will develop remediation actions, apply CPT/ICD-10 coding, and ensure accurate reimbursement by interpreting contracts and paying guidelines.

The role requires analyzing patterns, creating audit-ready documentation, and collaborating with clinical, IT, and provider relations teams to support health plan operations and quality programs.

Qualifications

• Bachelor’s degree in healthcare, finance, or related field required.
• 4+ years of relevant work experience in lieu of degree acceptable.
• Experience with contract interpretation (DOFR) and data analysis is essential.
• Strong understanding of CPT/ICD-10/HCPCS coding and medical billing concepts.

Responsibilities

• Investigate data mining leads, audit findings, and billing errors to identify overpayments.
• Develop remediation actions and update business rules and workflows.
• Apply coding systems and provider contracts to ensure accurate reimbursement.
• Prepare audit-ready case notes for disputes, appeals, and CART teams.
• Collaborate with clinical, IT, SIU/FWA, and provider relations teams to support health plan operations.

Skills

Data analysis

Analytical thinking

Problem-solving

Communication

Independent decision-making

Organizational skills

Education

Bachelor’s degree in healthcare, finance, or related field

4+ years of relevant work experience in lieu of degree

Tools

SQL

Microsoft Office Suite

Job description

• Independently investigate moderate-to-complex data mining leads, claim inventories, and audit findings for errors, including DRG validation and billing inaccuracies
• Determine error sources and recommend remediation actions
• Develop logic for data mining concepts based on overpayment identifications
• Utilize AI, predictive analytics, and SQL to identify patterns of improper spend, false positives, and trends
• Apply CPT, ICD-10, HCPCS, and NDC coding systems alongside provider contract terms to ensure accurate reimbursement
• Research and interpret CMS, DHCS, and industry billing guidelines
• Create detailed, audit-ready case notes and maintain documentation for disputes, appeals, and client inquiries
• Identify root causes of claim errors and suggest improvements to business rules and operational workflows
• Update business rules, system edits, configuration, and pre/post-pay controls to reduce recurring improper payment trends
• Collaborate with clinical, legal, IT, SIU/FWA, provider relations, Medical Economics, providers, and clients
• Deploy logic and run it against claims-paid data to produce overpayment reports
• Ensure claim activities comply with CMS regulations and internal policies
• Escalate potential fraud, waste, or abuse concerns to SIU/FWA teams
• Assist with provider inquiries, disputes, case summaries, claim validation, and appeals
• Create audit results information for the CART team for lettering and recovery
• Perform other duties required to support Health Plan operations and department business needs
• Support IEHP Quality Program goals, including HEDIS, CAHPS, and NCQA Accreditation

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
• 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
• Certification in RHIA, RHIT, CCS, CPC, CIC or similar certification preferred
• Strong understanding of medical coding (CPT, ICD-10, HCPCS) and health insurance contracts
• Strong understanding of the full claims lifecycle, including share of cost and coordination of benefits
• Strong understanding of Medicaid/Medi-Cal or Medicare regulatory frameworks
• Strong understanding of payment integrity concepts, including pre-pay audit, post-pay audit types, DRG validation, and coordination of benefits
• Intermediate 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

Core Competencies

Demonstrates expertise in healthcare claims processing, billing, and auditing, with a strong focus on data analysis and compliance with regulatory frameworks. Proficient in medical coding systems and capable of translating analytical findings into actionable operational improvements.

Highest-signal resume keywords

• Healthcare Claims Processing
• Data Analysis/Queries
• Medical Coding (CPT, ICD-10, HCPCS)
• Intermediate SQL
• Payment Integrity Concepts

ATS Optimization Keywords

Hard Skills

• Data Mining
• DRG Validation
• Billing Inaccuracies
• Predictive Analytics
• Overpayment Identification
• Audit Documentation
• Root Cause Analysis
• Business Rules Update
• Claims Lifecycle Understanding
• Contract Interpretation

Soft Skills

• Analytical Skills
• Problem-Solving
• Organizational Skills
• Effective Communication
• Independent Decision-Making

Certifications & Qualifications

• RHIA
• RHIT
• CCS
• CPC
• CIC

Industry Keywords

• CMS Regulations
• Medicaid/Medi-Cal
• Medicare
• HEDIS
• CAHPS
• NCQA Accreditation
• Fraud, Waste, and Abuse
• Provider Relations
• Audit-Ready Case Notes
• Operational Workflows

Tools & Technologies

• Microsoft Office Suite
• SQL