Senior Payment Integrity Analyst

Jobtailor

Rancho Cucamonga (CA)

On-site

USD 110,000 - 160,000

Full time

9 days ago

Get more replies from employers

Send a job-specific resume in minutes.

Job summary

Jobtailor seeks a lead-level analyst to drive payment integrity operations for health plans in California. You will QA junior analysts, lead vendor reporting, and collaborate on strategies to improve financial performance and cost containment.

The role requires five years of experience in payment integrity, claims auditing, or medical coding, with strong SQL and data visualization skills. Bachelor’s degree or equivalent experience is preferred.

Qualifications

Five years or more in payment integrity, claims auditing, or medical coding.
Strong data analysis and SQL querying experience.
Experience with contract and DOFR interpretation.
Bachelor’s degree in related field required or equivalent experience.
Knowledge of CMS, HIPAA, DRG, ICD-10, CPT coding preferred.

Responsibilities

Provide lead-level analyst support for daily operations of payment integrity vendors and internal programs.
Lead reporting and tracking of vendor activity to management.
Work with leaders to improve health plan financial performance.
Review pre- and post-pay claims to identify improper payments and cost leakage.
Develop audit data-mining techniques to detect irregularities and trends.
Analyze large datasets using SQL and Excel to identify root causes.

Skills

Data Analysis

Claims Auditing

Medical Coding

SQL

Excel

Data Visualization

Billing Regulations

DRG Coding

CPT Coding

Fraud Detection

Education

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

4+ years of additional relevant work experience in lieu of degree

Tools

Data Visualization Tools

Audit Tracking Tools

Dashboards

Job description

Provide lead-level analyst support for daily operations of payment integrity vendors and internal programs
Perform quality assurance of junior analysts’ work and act on remediation plans to develop cost avoidance opportunities
Lead reporting and tracking of vendor activity, including daily and monthly reporting to management
Partner with leaders and functional representatives to improve health plan financial performance through payment integrity and provider claims accuracy initiatives
Make recommendations informing health plan strategy and help resolve complex cost-containment and regulatory-compliance challenges
Lead efforts to improve claim payment accuracy and financial performance
Review pre- and post-pay claims to identify overpayments, underpayments, and billing inaccuracies
Develop and refine audit data-mining techniques to detect irregularities, billing trends, and potential Fraud, Waste, and Abuse (FWA)
Analyze large datasets using SQL and Excel to identify trends, anomalies, and root causes of payment errors
Design and maintain dashboards, trend analyses, and audit tracking tools
Work with providers to resolve payment discrepancies and defend or challenge reimbursement decisions
Conduct comprehensive reviews of inpatient/outpatient claims, itemized bills, and DRGs to identify improper payments
Serve as subject‑matter expert for CMS/DHCS regulatory interpretation and operational application in audit strategies, system edits, and business rules
Provide training, coaching, and quality‑control support to junior analysts
Oversee vendor audit pipelines, validate findings, monitor performance metrics, generate financial impact reports, and ensure methodologies align with contractual and regulatory standards
Interpret and apply federal/state regulations and provider contract terms for audits
Ensure requirements are met for pre-pay edits, post-payment datamining, and overpayment recovery
Collaborate with leadership to develop audit concepts, test system edits, and reduce financial leakage
Analyze and resolve provider inquiries and appeals regarding payment adjustments
Prepare appeal defense packages, analyze overturn trends, and recommend process improvements
Perform other duties as required to support Health Plan operations and department needs

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; 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
Strong knowledge of billing regulations (CMS, HIPAA), DRG, ICD-10, and CPT coding
Knowledge of medical coding (CPT, ICD-10, HCPCS) and health insurance contracts
Knowledge of the full claims lifecycle, including share of cost and coordination of benefits
Knowledge of Medicaid/Medi-Cal or Medicare regulatory frameworks
Knowledge of payment integrity concepts
Knowledge of data file layouts and system configurations
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
Proven ability to work independently and apply business judgment in a highly regulated, cross-functional environment

Core Competencies

Demonstrates expertise in payment integrity, claims auditing, and medical coding, with strong analytical skills to identify trends and anomalies in large datasets. Proficient in regulatory compliance and contract interpretation, ensuring accurate claims processing and financial performance.

Highest-signal resume keywords