Payment Integrity Analyst

About the role

The Payment Integrity Analyst monitors the overpayment inventory and performs analysis of claims, coding, contracts, and clinical documentation to identify improper payments, validate audit findings, and develop remediation recommendations and actions. This position leverages data analytics, audit methodologies, and regulatory expertise to detect reimbursement inaccuracies, support overpayment recovery processes, and mitigate future risk. This role collaborates with cross-functional teams including clinical, legal, SIU/FWA, provider relations, and IT to assess patterns of improper spend and implement sustainable solutions. The role maintains audit-ready documentation, contributes to business rule enhancements, and supports operational improvements that strengthen payment accuracy and incremental savings opportunities across the claims lifecycle.

The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Responsibilities

• Monitor overpayment inventory and perform analysis of claims, coding, contracts, and clinical documentation
• Identify improper payments and validate audit findings
• Develop remediation recommendations and actions
• Leverage data analytics, audit methodologies, and regulatory expertise to detect reimbursement inaccuracies
• Support overpayment recovery processes and mitigate future risk
• Collaborate with cross-functional teams (clinical, legal, SIU/FWA, provider relations, IT) to assess patterns of improper spend
• Implement sustainable solutions to strengthen payment accuracy
• Maintain audit-ready documentation
• Contribute to business rule enhancements and operational improvements

Requirements

• A minimum of three (3) years of experience in a combination of healthcare claims processing, billing, and/or auditing functions
• Experience with contract and Division of Financial Responsibility (DOFR) interpretation
• Experience with data analysis/queries
• Bachelor’s degree in healthcare, finance, or a related field from an accredited institution or a minimum of four (4) years of additional relevant work experience (in lieu of the degree)
• Certification in RHIA, RHIT, CCS, CPC, CIC or similar certification preferred

Qualifications

• Strong understanding 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
• Familiarity with Medicaid/Medi-Cal or Medicare regulatory frameworks
• Understanding of payment integrity concepts (pre-pay audit, post-pay audit types, DRG validation, coordination of benefits, and comparable concepts)
• Intermediate proficiency in SQL and Microsoft Office Suite (Excel, Access)
• Demonstrated ability to make independent decisions in claim coding and adjudication
• Strong analytical, problem-solving, and trend analysis skills
• Ability to translate analytical findings into operational recommendations
• Solid organizational and planning capabilities
• Effective communication with internal stakeholders and external parties
• Ability to independently prioritize caseloads based on impact and timelines

Benefits

• Competitive salary
• State-of-the-art fitness center on-site
• Medical insurance with dental and vision coverage
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development
• Wellness programs promoting 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

Pay

$80,059.20 USD Annually - $106,059.20 USD Annually