Senior Payment Integrity Analyst

About the role

Reporting to the Manager, Payment Integrity Operations, the Senior Payment Integrity Analyst provides lead-level analyst support to a team of Payment Integrity Analysts on daily operations of vendor(s) and internal programs for Payment Integrity. The incumbent provides quality assurance of junior analysts’ work and action on remediation plans to develop cost avoidance opportunities. This position leads the reporting and tracking of all vendor activity to provide daily and monthly reporting to management. The Senior Payment Integrity Analyst partners with leaders and functional representatives to drive health plan financial performance through evaluation and execution of operational initiatives tied to payment integrity (PI) and provider claims accuracy. The role makes recommendations that inform decisions contributing to health plan strategy and acts as a trusted voice in assessing and assisting resolution of complex business challenges that impact cost-containment and regulatory compliance.

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

Responsibilities

• Provide lead-level support to a team of Payment Integrity Analysts on daily operations of vendor(s) and internal programs.
• Perform quality assurance of junior analysts’ work and action remediation plans to develop cost avoidance opportunities.
• Lead the reporting and tracking of all vendor activity to provide daily and monthly reporting to management.
• Partner with leaders and functional representatives to drive health plan financial performance through evaluation and execution of operational initiatives tied to payment integrity and provider claims accuracy.
• Make recommendations that inform decisions contributing to health plan strategy.
• Assess and assist in resolving complex business challenges impacting cost-containment and regulatory compliance.
• Analyze data to inform business decisions and troubleshoot remediation efforts with IT and vendors.

Requirements

• A minimum of five (5) years of experience in a combination of payment integrity, claims auditing, and/or medical coding.
• Strong data analysis/queries experience.
• Experience with contract and Division of Financial Responsibility (DOFR) interpretation.
• Bachelor’s degree in business, health administration, or a related field from an accredited institution. In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required (in addition to the five years listed above).
• Certification in RHIA, RHIT, CCS, CPC, CIC, or similar certification preferred.

Qualifications

• Strong knowledge and deep understanding of billing regulations (CMS, HIPAA), DRG, ICD-10, and CPT coding.
• Proficiency in medical coding (CPT, ICD-10, HCPCS) and health insurance contracts.
• Understanding of the full claims lifecycle, including share of cost and coordination of benefits.
• Familiarity with Medicaid/Medi-Cal or Medicare regulatory frameworks.
• Knowledge of payment integrity concepts (pre-pay audit, post-pay audit types, DRG validation, coordination of benefits, and comparable concepts).
• Experience with data file layouts and system configurations to troubleshoot and coordinate remediation efforts.
• Strong analytical skills with the ability to analyze large datasets and identify patterns.
• Strong proficiency in SQL, data visualization tools, and MS Excel.
• Strong written and verbal communication skills, including the ability to synthesize complex information.
• Proven ability to work independently and apply business judgment in a highly regulated, cross-functional environment.

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 that promote 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

Pay Range: $91,249.60 USD Annually - $120,910.40 USD Annually