Payment Integrity Analyst

Inland Empire Health Plan•Rancho Cucamonga, CA

1d•$80,059 - $106,059•Remote

About The Position

Reporting to the Manager, Payment Integrity Operations, 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.

Requirements

A minimum of three (3) years of experience in a combination of healthcare claims processing, billing, and/or auditing functions required.
Experience with contract and Division of Financial Responsibility (DOFR) interpretation.
Experience with data analysis/queries experience.
Bachelor’s degree in healthcare, finance, or a related field from an accredited institution required.
In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position.
This experience is in addition to the minimum years listed in the Experience Requirements above.
Strong understanding of: Medical coding (CPT, ICD-10, HCPCS) and health insurance contracts.
Strong understanding of: The full claims lifecycle, including share of cost and coordination of benefits.
Strong understanding of: Medicaid/Medi-Cal or Medicare regulatory frameworks.
Strong understanding of: Payment integrity concepts (pre-pay audit, post-pay audit types, DRG validation, coordination of benefits and comparable concepts).
Intermediate in SQL and Microsoft Office Suite (Excel, Access) required.
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.
Ability to communicate effectively with internal stakeholders and external parties.
Ability to independently prioritize caseloads based on impact and timelines.

Nice To Haves

Certification in RHIA, RHIT, CCS, CPC, CIC or similar certification preferred.

Responsibilities

Independently investigate moderate-to-complex data mining leads, claim inventories, and audit findings for errors, including DRG (Diagnosis-Related Group) validation and billing inaccuracies to determine error sources and recommend remediation action.
Develop logic for data mining concepts based on overpayment identifications through current work processes.
Utilize AI, predictive analytics, and SQL to identify patterns of improper spend, false positives, and trends.
Apply knowledge of CPT, ICD-10, HCPCS, and NDC coding systems alongside provider contract terms to ensure accurate reimbursement.
Research and interpret CMS, DHCS, and industry billing guidelines to ensure claims analysis reflects the most current regulatory requirements.
Create detailed, audit-ready case notes and maintain documentation for disputes, appeals, and client inquiries.
Identify root causes of claim errors and suggest improvements to business rules and operational workflows.
Identify opportunities to update business rules, system edits, configuration, and pre/post-pay controls to reduce recurring improper payment trends.
Interact with cross-functional teams (clinical, legal, IT) and external stakeholders (providers, clients) to resolve discrepancies, validate clinical appropriateness, ensure documentation adequacy, and coding alignment for claims across all lines of business.
Work with the Medical Economics team to deploy logic and run against claims paid data producing an overpayment report.
Ensure all claim activities comply with CMS regulations and internal policies.
Escalate potential fraud, waste, or abuse concerns to SIU/FWA teams and collaborate on investigative handoffs as appropriate.
Assist in responding to initial-level provider inquiries or disputes by preparing case summaries, validating claim findings, and supporting the appeals process under the guidance of senior analysts.
Create audit results information to provide to CART team for lettering and recovery.
Perform any other duties as required to ensure Health Plan operations and department business needs are successful.