Payment Integrity Policy Analyst

If you’re passionate about medical coding accuracy, payment integrity, and making a meaningful impact on healthcare affordability and quality, this is your opportunity to make a difference for our members and providers.

About the role

This role is key in shaping health plan strategies, providing expert insights to address complex challenges related to cost containment and regulatory compliance. It offers a unique chance to influence strategy, develop new policies, and collaborate with a team that truly values both coding expertise and payment integrity excellence.

Opportunity to use multiple skills sets – medical coding, claims reimbursement, data analytics, contract research, regulatory compliance, provider appeals, and process improvement. Direct influence on organizational strategy and measurable financial results.

Responsibilities

• Investigate and identify market industry trends.
• Perform data analytics to analyze the financial performance of our provider sponsors and risk panels.
• Research contracts to ensure compliance with recommended payment integrity policies.
• Present recommended payment integrity policies to executive team and provider sponsors.
• Create and maintain payment integrity policy for external communication.
• Lead cross-functional teams to implement payment integrity policies.
• Review, analyze, and respond to internal or external audits related to payment integrity policy.
• Analyze regulatory compliance and market industry trends regarding payment integrity policy to continue to align with market and be compliant with federal, state, and ERISA regulations.
• Review and respond to escalated provider payment integrity policy appeals.

Qualifications

• Bachelor's degree with 2+ years of payment integrity, coding integrity or revenue integrity experience OR associate degree with 5+ years of payment integrity, coding integrity, or revenue integrity experience OR high school equivalency with 8+ years of payment integrity, coding integrity, or revenue integrity experience.
• Completion of a medical coding program, health information technology, or health information management.
• Certification in CPC, COC, RHIT, RHIA, CCA, and/or CCS.
• Ability to demonstrate understanding of CMS and commercial payer policy in written and verbal format.
• Strong understanding of claim process, ICD-10 coding, DRG validation, etc.
• Strong understanding of healthcare revenue cycle and claims reimbursement.
• Proficient in data analytic tools.
• Comfortable interfacing with providers at the executive level.
• Demonstrate ability to manage multiple projects, set priorities, and adhere to committed schedule.
• Strong interpersonal skills and adaptive communication style, complex problem solving, drive for results, innovative.
• Excellent written and verbal communication skills including ability to synthesize complex information.
• Proven track record of delivering concrete results in strategic projects/programs.
• Strong analytical ability and distilling data into actionable results.

Hardware and equipment will be provided by the company, but candidates must have access to high-speed, non-satellite Internet to successfully work from home.

Benefits

We offer an excellent benefit and compensation package, opportunity for career advancement and a professional culture built on the foundations of Respect, Responsibility, Resourcefulness and Relationships.

Pay

Starting salary is based upon skills and experience: $72,500 - $90,600 plus robust benefits package.