Payment Integrity Business Analyst

Sagility

United States

On-site

USD 60,000 - 100,000

Full time

14 days+

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Benefits offered by this job

Medical

Vision

Life Insurance

Short-Term and Long-Term Disability

Flexible Spending Account

Life Assistance Program

401K with employer contribution

PTO and Sick Time

Tuition Reimbursement

Job summary

An established industry player is seeking a talented Payment Integrity Business Analyst to enhance payment processes in healthcare. This role requires strong analytical skills to identify overpayment opportunities and improve workflows. The ideal candidate will collaborate with cross-functional teams, ensuring compliance with regulations while driving process improvements. With a focus on data analysis and stakeholder collaboration, this position offers a chance to make a significant impact in optimizing payment integrity. Join a dynamic team that values innovation and efficiency in delivering high-quality care.

Qualifications

5+ years of experience in healthcare reporting and analytics.
Strong analytical skills and ability to work in cross-functional teams.

Responsibilities

Analyze claims data to identify trends and discrepancies.
Collaborate with IT and operational teams for process improvements.
Ensure compliance with healthcare regulations.

Skills

Data Analysis

Healthcare Reporting

SQL

Excel

Collaboration

Project Management

Communication

Education

Bachelor's Degree in a related field

5+ years of experience in healthcare analytics

Tools

Tableau

Power BI

Job description

Sagility is a tech-enabled BPM services provider, a thought partner providing a broad spectrum of transformational services, to enable our clients provide efficient and hi-quality care across the healthcare system.

Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. We optimize the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics.

Leading industry analyst firms have consistently cited our service excellence, breadth of offerings, and ability to execute. The most recent being recognized as a leader for Healthcare Payer Operations in 2022 as a part The Healthcare Payer Operations PEAK Matrix Assessment report by Everest Group. We have 38,000+ employees in 15 cities across 5 countries – India, Philippines, USA, Jamaica, and Colombia.

About SPIS (Sagility Payment Integrity Services)

Sagility’s approach to Payment Integrity (PI) is a collaboration between our Data Mining, Coding and Clinical teams that provides predictable operational excellence through analytics-led, technology-driven solutions. Backed by our proprietary Intelligent Content Processing (ICP) software, we deliver high quality, broad automation driven for more accurate audit findings. Through our HITRUST certified platform, Contract Central, we provide Data Mining, Clinical and Claims Repricing solutions that enhance claims payment accuracy and ensure significant savings in both pre and post-pay.

Our team is currently seeking a talented Payment Integrity Business Analyst who will focus on Audit and help the user identify overpayment opportunities or to support analysis and review of activity for reporting and process improvement purposes. This role is a strong partner with the Audit team to resolve claims issues, pricing, and fix contract issues; as needed, the candidate will interact with the IT team to obtain assistance where needed.

Job Summary:

The Payment Integrity Business Analyst will play a pivotal role in analyzing and improving payment processes within a healthcare organization. This role requires an individual who is highly analytical and is comfortable working in a less defined work environment with cross-functional teams to optimize payment workflows, detect errors, and ensure compliance with internal and external regulations.

Key Area of Responsibilities:

Data Analysis & Reporting:

Analyze and evaluate claims data to identify trends, discrepancies, and areas where claims may be inaccurately paid or healthcare rules/policies have been inaccurately applied.
Locate provider agreements and payment rules within a client's systems and load to the Sagility proprietary platform.
Review and validate potential overpayments by verifying against independent sources of truth such as provider agreements, state or CMS rules, etc.
Fix contract-pricing issues with Audit staff.
Review and reconcile payment discrepancies, ensuring that claims are processed correctly according to the payer guidelines, contracts, and industry standards.
Collaborate with Claims and Billing teams to resolve payment errors and ensure accurate payments to providers.
Investigate overpayments, underpayments, and claim denials, working with the team to identify root causes and implement corrective actions.

Process Improvement:

Identify and document business requirements for process improvements aimed at reducing payment discrepancies and enhancing the efficiency of the payment lifecycle.
Collaborate with IT and operational teams to design, test, and implement process improvements, automation tools, or system upgrades.
Recommend solutions to reduce administrative costs and improve payment accuracy.

Compliance & Regulatory Adherence:

Ensure that all payment integrity activities comply with applicable healthcare regulations (such as HIPAA, Medicare/Medicaid guidelines, and payer contracts).
Monitor and audit payment processes to ensure adherence to internal policies and external regulatory standards.
Support internal and external audits related to payment integrity.

Stakeholder Collaboration:

Serve as a liaison between business teams, IT, providers, and external stakeholders to communicate issues, solutions, and process improvements related to payment integrity.
Conduct training sessions and workshops for internal teams on payment accuracy, reconciliation procedures, and the use of relevant tools or systems.
Provide ongoing support for payment-related queries and assist in troubleshooting payment-related issues.
Leverage payment integrity systems and software tools to track and monitor claims and payment discrepancies.
Collaborate with IT to ensure proper system functionality and data integration across platforms.
Utilize advanced Excel functions, SQL queries, or business intelligence tools (e.g., Tableau, Power BI) to perform complex data analysis.

Education & Experience:

Understanding of claims processing and the lifecycle of a claim.
5 plus years of experience with healthcare reporting and analytics required.
Knowledge of healthcare economics.
Experience with CMS inpatient and outpatient claim regulations.
Experience with State Medicaid pricing.
Experience with relational and non-relational databases.
Knowledge of ICD10, CPT, DRG coding.
Experience identifying and measuring business trends.
Project Management experience researching system enhancements.
Strong people skills to communicate with a wide range of auditor skillsets.
Strong collaboration skills and ability to work independently and as part of a team.
Ability to thrive in a fast-paced, changing environment.
Ability to create understanding of and obtain buy-in on proposed solutions.
Strong organizational skills with the ability to manage multiple priorities and deadlines.

Preferred Skills:

Knowledge of ICD10, CPT, DRG coding.

Sagility Offers Competitive Benefits Including: