Senior Payment Integrity Analyst

Community Care Plan; Florida; Híbrido; USD 90.000 - 130.000; Jornada completa

Descripción de la vacante

Community Care Plan is seeking an experienced Senior Payment Integrity Analyst to lead payment integrity across Medicaid and Marketplace lines of business. You will drive strategies to prevent, detect, and recover improper medical claims while collaborating with Finance, IT, Compliance, Claims, Quality, Risk Adjustment, and external partners to improve accuracy and protect healthcare dollars.

Ideal candidates bring 5+ years in data roles within health plans, plus strong SQL and Power BI skills,

Formación

• Bachelor's degree required or 5+ years of relevant work experience.
• 5+ years in a data-related role within a health plan.
• Experience with payment integrity in a Managed Medicaid health plan.
• Strong knowledge of SQL and Power BI.
• Experience with Marketplace lines of business is preferred.
• Experience with claims and encounter data within a health plan is preferred.

Responsabilidades

• Lead payment integrity strategies to prevent, detect, and recover improper medical claims.
• Oversee pre-payment and post-payment review and cost-containment initiatives.
• Evaluate and manage payment integrity vendors.
• Identify and correct contract configuration and claims processing errors.
• Oversee claim editing strategies, including duplicate detection, upcoding, and unbundling.
• Perform root cause analysis and collaborate with Claims, IT, Provider Operations, Compliance, Finance, and other teams to implement solutions.
• Analyze data and clearly communicate findings to technical and non-technical stakeholders.
• Develop and maintain standard operating procedures and process guides.

Conocimientos

Claims data

Power BI

SQL

Marketplace knowledge

Data analysis

Educación

Bachelor's degree in Healthcare, Finance, or related field

Descripción del empleo

Community Care Plan is seeking an experienced Senior Payment Integrity Analyst to serve as a key business lead for payment integrity across our Medicaid and Marketplace lines of business. In this role, you’ll help drive strategies that prevent, detect, and recover improper medical claims while working closely with Finance, IT, Compliance, Claims, Quality, Risk Adjustment, and external partners to improve payment accuracy and protect healthcare dollars.

What You Bring

• Bachelor’s degree in Healthcare, Finance, or a related field or 5+ years of relevant work experience
• 5+ years of experience in a data-related role within a health plan, preferably involving claims and encounter data
• Experience with payment integrity within a Managed Medicaid health plan, preferably in Florida
• Strong knowledge of SQL and Power BI
• Experience with Marketplace or commercial lines of business is preferred
• Experience working with claims and encounter data and processes within a health plan is preferred

What You’ll Do

• Lead payment integrity strategies designed to prevent, detect, and recover improper medical claims
• Oversee pre-payment and post-payment claim review and cost-containment initiatives
• Evaluate and manage payment integrity vendors
• Identify and correct contract configuration and claims processing errors
• Oversee clinical and non-clinical claim editing strategies, including duplicate detection, upcoding, and unbundling
• Perform root cause analysis and partner with Claims, IT, Provider Operations, Compliance, Finance, and other teams to implement solutions
• Analyze data and clearly communicate findings and recommendations to technical and non-technical stakeholders
• Develop and maintain standard operating procedures and process guides

Why This Role Matters

This is an opportunity to play a key role in shaping payment integrity strategy across a health plan environment—combining data analysis, healthcare operations, problem-solving, and cross-functional leadership to help ensure claims are processed accurately and payment integrity programs are effective.

Work Schedule:

Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee may occasionally be required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion.

In compliance with Florida law, candidates selected for this position must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse.

The Clearinghouse is a statewide system managed by the Agency for Health Care Administration (AHCA) and is designed to help protect children, seniors, and other vulnerable populations while streamlining the screening process for employers and applicants.

Additional information is available at: https://info.flclearinghouse.com