Payment Integrity Analyst

About the Role

The Payment Integrity Analyst provides quality and operational support for PACE program administration, including claims auditing support, testing, data analysis, issue resolution, systems support, and process improvement initiatives. This role supports internal teams, external partners, and stakeholders to ensure accurate and efficient network operations across claims processing, provider data management, and claims customer services.

Responsibilities

• Analyze, troubleshoot, and resolve operational issues related to claims, provider networks, and benefits.
• Act as a liaison between internal departments (e.g., IT, claims, customer service) and external vendors or PACE program partners.
• Monitor claims quality and integrity in systems and work with IT or other teams to resolve discrepancies.
• Maintain documentation of workflows, business rules, and process changes.
• Support the implementation of newly covered services and upgrades through coordination with cross-functional teams.
• Create and distribute reports, provide analyses to support business decisions and ensure compliance with regulatory requirements.
• Assist with testing system updates and enhancements, including user acceptance testing (UAT).
• Identify process improvement opportunities and participate in initiatives to enhance operational efficiency and member experience.
• Stay updated on regulatory and industry changes affecting PACE program operations.

Requirements

• Bachelor’s degree in healthcare administration, business, or related field, or equivalent work experience.
• 4+ years of experience in a claims healthcare environment or health insurance.
• Strong analytical and problem-solving skills.
• Proficient in Microsoft Excel, with experience using data tools and reporting software.
• Excellent written and verbal communication skills.
• Ability to work independently and collaboratively in a fast-paced environment.

Preferred Qualifications

• Experience with payer health plan systems (e.g., Plexis, Facets, QNXT, Epic Tapestry, or similar).
• Knowledge of HIPAA, Medicare, Medicaid, or ACA regulations.
• SQL or other data query skills.

Benefits

• Medical, dental, and vision insurance.
• Short and long-term disability, life insurance, and AD&D.
• Supplemental life insurance.
• Flexible spending accounts.
• 401(k) savings plan with company match.
• Paid time off and company-paid holidays.

Pay

Posted pay range: $77,400 - $96,800.

This position requires a background screening through the Florida Care Provider Background Screening Clearinghouse for Florida applicants.