Strategic Payment Integrity Lead — Medicaid & Data Analytics

Community Care Plan; Town of Florida (NY); Hybrid; USD 100,000 - 150,000; Full time

Benefits offered by this job

Hybrid work schedule

Job summary

Community Care Plan is recruiting a Senior Payment Integrity Analyst to lead enterprise-wide payment integrity initiatives across Medicaid and Marketplace lines. The role coordinates with Finance, IT, Compliance, and Claims to prevent, detect, and recover improper claims.

The position requires strong SQL and Power BI skills, a healthcare/finance background, and at least 5 years in data-related health-plan work, preferably Florida-based.

Qualifications

• Bachelor’s degree in Healthcare, Finance, or a related field, or five (5) or more years of relevant work experience.
• Minimum of 5 years of experience in a data-related role within a health plan, preferably with claims and encounter data.
• Prior experience with payment integrity within a Managed Medicaid health plan preferably in Florida.
• Strong knowledge of SQL and Power BI.

Responsibilities

• Direct enterprise-wide strategy to prevent, detect, and recover improper medical claims.
• Oversee cost-containment programs and ensure regulatory compliance.
• Evaluate and manage vendors related to payment integrity.
• Design and implement strategies to identify and correct errors in contract configuration.
• Ensure claims are processed accurately per all contractual/state/federal updates.
• Lead pre- and post-payment reviews and monitoring activities.
• Oversee claim-editing systems for issues like duplicates, upcoding, and unbundling limits.
• Communicate with Compliance, Claims, Finance, and IT regularly.

Skills

SQL

Power BI

Data analysis

Education

Bachelor's degree in Healthcare/Finance or related field

Job description

Community Care Plan is recruiting a Senior Payment Integrity Analyst to lead enterprise-wide payment integrity initiatives across Medicaid and Marketplace lines. The role coordinates with Finance, IT, Compliance, and Claims to prevent, detect, and recover improper claims.

The position requires strong SQL and Power BI skills, a healthcare/finance background, and at least 5 years in data-related health-plan work, preferably Florida-based.