Payment Accuracy Analyst, Senior - Hybrid

UPMC•Pittsburgh, PA

3d•Hybrid

About The Position

Are you passionate about ensuring accuracy and driving efficiency in healthcare reimbursement? At UPMC Health Plan, we're looking for a Senior Payment Accuracy Analyst to play a critical role in shaping how claims are processed and paid. This is your opportunity to make a real impact on payment integrity and compliance while collaborating with talented teams across the organization. This position is hybrid. There is an in-office requirement of at least once per month. Additional time in the office may be required based on business needs.

Requirements

Deep knowledge of coding standards and claim editing (AMA, CMS, NCCI).
Ability to analyze complex data, identify root causes, and recommend solutions.
Excellent communication skills to work with leadership and cross-functional teams.
A proactive mindset to lead projects and drive continuous improvement.
Bachelor's degree and 4 years of relevant experience OR equivalent combination of education & work within healthcare payers/claims payment processing will be considered
Ability to interpret claim edit rules and references
Solid understanding of claims workflow and the ability to interpret professional and facility claim forms
Ability to apply industry coding guidelines to claim processes
Ability to perform audits of claims processes and apply root-cause
Significant experience with Excel for data analysis and creating reports for senior management
Excellent verbal & written communication skills

Nice To Haves

Prior work experience in Claim Editing, Payment Integrity, or other healthcare claims operations-related fields is strongly preferred.
Prior experience with clinical coding and/or medical record review.
Prior experience with policy research (CMS, PA State Medicaid, etc), interpretation, and source documentation.
Previous experience with SQL, Power BI and or Tableau highly preferred.
Current certified coder (CCS, CCS-P or CPC), or Registered Health Information Technician (RHIA/RHIT) preferred, but not required
Familiarity with relational databases, such as Microsoft Access, SQL, etc.

Responsibilities

Collaborate across teams: Partner with Claims Operations, Medical Policy, IT, and more to align edits with clinical and financial goals.
Lead impactful projects: Drive initiatives that monitor and adapt to changes in payment and medical policy.
Be the subject matter expert: Advise leadership on coding and policy changes, ensuring edits work as intended and meet compliance standards.
Stay ahead of the curve: Keep up with industry trends, regulatory updates, and evolving payment models.
Turn data into decisions: Analyze data, spot meaningful patterns, and translate those insights into clear guidance that drives action.