Payment Analyst

About You

You are a person who loves to identify discrepancies, prevent overpayments, and ensure adherence to regulatory, contractual, and coding guidelines. We need someone who has expertise in medical coding, reimbursement methodologies, and healthcare policy and can apply that expertise to develop, implement, and maintain claims editing rules and audit processes.

Key Responsibilities

• Lead complex claim audits and investigations involving high-risk or high-value claims
• Design, develop, and maintain advanced claims editing rules and logic
• Translate complex regulatory and reimbursement policies into system specifications
• Oversee testing, validation, and implementation of editing rules
• Conduct root cause analysis and recommend systemic solutions
• Monitor CMS, OIG, and regulatory updates; ensure organizational compliance
• Act as SME for coding, billing, and payment integrity methodologies
• Mentor junior analysts and provide technical guidance
• Collaborate with IT, policy, and leadership teams on strategic initiatives
• Support benefit configuration and optimization in platforms like TriZetto Facets
• Present findings, insights, and recommendations to leadership

Claims Review & Audit

• Perform pre-pay and post-pay reviews of medical claims for accuracy, medical necessity, and compliance
• Identify billing errors including duplicate claims, unbundling, upcoding, and modifier misuse
• Ensure alignment with Tricare and VA Policy, CMS, state regulations, and payer-specific policies

Payment Integrity & Recovery

• Detect and quantify overpayments and support recovery efforts
• Analyze claim patterns to identify systemic issues and cost-saving opportunities
• Partner with recovery vendors and internal teams to resolve discrepancies

Policy & Rule Development

• Interpret healthcare policies (Tricare/VA Policy, CMS manuals, NCCI edits, LCDs/NCDs, fee schedules)
• Translate regulatory and coding guidance into automated claims editing logic
• Define rule specifications, decision pathways, and acceptance criteria
• Support configuration and optimization of claims editing platforms (e.g., Optum CES)

Data Analysis & Validation

• Analyze large datasets to identify trends, anomalies, and root causes of payment errors
• Develop SQL queries and reports to support audit findings and rule validation
• Perform testing and validation of editing rules and system configurations

Regulatory Monitoring & Compliance

• Monitor updates from Tricare and VA Policy, CMS, OIG, and industry sources for regulatory changes
• Maintain compliance with federal and state healthcare laws and reimbursement policies
• Support development and maintenance of medical policies and procedures

Collaboration & Communication

• Work cross-functionally with claims, IT, clinical, compliance, and Client Policy teams
• Serve as a subject matter expert (SME) on coding, billing, and payment integrity issues
• Communicate findings, policy interpretations, and recommendations to stakeholders

Minimum Requirements

• Ace's or Bachelor's degree in Health Administration, Public Health, Business, or related field (or equivalent experience)
• 5+ years of experience in healthcare claims, payment integrity, auditing, or revenue cycle
• Advanced expertise in coding systems, reimbursement methodologies, and CMS regulations
• Strong experience with claims editing platforms (e.g., Optum CES)
• Advanced SQL and data analysis skills
• Demonstrated experience in rule development and system configuration
• Experience with Tricare and Veterans Administration, Medicare, Medicaid, and/or commercial reimbursement methodologies
• Hands-on experience with claims adjudication and editing systems
• Strong knowledge of: CPT, HCPCS, ICD-10 coding systems, NCCI edits and CMS guidelines
• Proficiency in: SQL and data analysis, Excel (pivot tables, VLOOKUP, data manipulation)
• Experience with EDI transactions, CMS-1500, and claims workflows
• One or more of the following: CPC (Certified Professional Coder), CCS / CCS-P (Certified Coding Specialist), RHIT / RHIAS
• Strategic thinking, leadership, and mentorship
• Advanced analytical and technical skills
• Deep regulatory and policy expertise
• Strong decision-making and problem-solving ability

About Us

We are looking for people to help us in our mission of working hard at lowering healthcare administrative costs for federal government agencies, payers, and providers. At Signature, our mission is to improve the health of our clients' business and make the lives of the people we work with better. As we continue to experience exponential growth, we are looking for uncommon individuals to enhance our vision. We will continue to accomplish our mission by leading with our values of Passion, Courage, Integrity, and Respect in all interactions, making us a consistent annual Best Places to Work organization.

About The Benefits

• Health Insurance
• Fully Paid Life Insurance
• Fully Paid Short- & Long-Term Disability
• Paid Vacation
• Paid Sick Leave
• Paid Holidays
• Professional Development and Tuition Assistance Program
• 401(k) Program with Employer Match