Senior Payment Integrity Lead - Medicaid & Marketplace

Community Care Plan; Florida; Hybride; USD 90 000 - 130 000; Plein temps

Résumé du poste

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,

Qualifications

• 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.

Responsabilités

• 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.

Connaissances

Claims data

Power BI

SQL

Marketplace knowledge

Data analysis

Formation

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

Description du poste

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,