Senior Payment Integrity Analyst

Inland Empire Health Plans; Rancho Cucamonga (CA); On-site; USD 105,000 - 135,000; 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 disa​b

Career advancement opportunities and专业

Wellness programs

Flexible Spending Account – HealthCare

CalPERS retirement

457(b) plan with match

Paid life insurance

Pet care insurance

Job summary

Inland Empire Health Plans (IEHP) is seeking a Senior Payment Integrity Analyst to lead a team of analysts and oversee daily operations of payment integrity initiatives. You will ensure accuracy of provider claims and drive cost avoidance through remediation plans.

Reporting to the Manager, Payment Integrity Operations, you will deliver daily and monthly reports, support quality assurance, and collaborate with IT and vendors to improve financial performance while maintaining regulatory

Qualifications

• Minimum of five (5) years in payment integrity, claims auditing, and/or medical coding.
• Strong data analysis and queries experience.
• Experience with contract interpretation and Division of Financial Responsibility (DOFR).
• Bachelor’s degree in business, health administration, or a related field from an accredited institution.
• Certification in RHIA, RHIT, CCS, CPC, CIC or similar certification preferred.

Responsibilities

• Lead a team of Payment Integrity Analysts on daily operations of vendor activities and internal programs.
• Provide quality assurance of junior analysts’ work and remediation plans to drive cost avoidance.
• Lead reporting of vendor activity with daily and monthly management reports to drive financial performance.
• Collaborate with leaders and IT/vendors to ensure regulatory compliance and provider claims accuracy.

Skills

Data analysis

SQL

MS Excel

Education

Bachelor's degree in business, health administration, or related field

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 Senior Payment Integrity Analyst provides lead level analyst support to a team of Payment Integrity Analysts on daily operations of vendor(s) and internal programs for Payment Integrity. The incumbent provides quality assurance of junior analysts’ work and action on remediation plans to develop cost avoidance opportunities. This position leads the reporting and tracking of all vendor activity to provide daily and monthly reporting to management. The incumbent partners with leaders and functional representatives to drive health plan financial performance through evaluation and execution of operational initiatives tied to payment integrity (PI) and provider claims accuracy. The Senior Payment Integrity Analyst makes recommendations that inform decisions which contribute to health plan strategy, and acts as a trusted voice in assessing and assisting resolution of complex business challenges that impact cost-containment and regulatory compliance.

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 five (5) years of experience in a combination of payment integrity, claims auditing, and/or medical coding required


• Strong data analysis/queries experience


• Experience with contract and Division of Financial Responsibility (DOFR) interpretation


• Bachelor’s degree in business, health administration, 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 knowledge and deep understanding of:
  
  
  
  • Billing regulations (CMS, HIPAA), DRG, ICD-10, and CPT coding
  
  
  • 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)
  
  
  • Data file layouts and system configurations to troubleshoot and coordinate remediation efforts with IT and vendors
  
  


• Strong analytical skills with the ability to analyze large datasets and identify patterns


• Strong proficiency in SQL, data visualization tools, and MS Excel


• Strong written and verbal communication skills, including ability to synthesize complex information


• Proven ability to:
  
  
  
  • Analyze data to inform business decisions
  
  
  • Work independently and apply business judgment in a highly regulated, cross-functional environment
  
  

Start your journey towards a thriving future with IEHP and apply TODAY!