Payment Integrity Analyst II

Texas Children's Hospital•Bellaire, TX

18h

About The Position

As a Payment Integrity Analyst II at Texas Children’s Health Plan, you’ll help improve claims-payment accuracy, support cost-reduction initiatives, and ensure compliance with payment policies and regulations. You’ll analyze data, identify payment trends, collaborate with internal teams and vendors, and develop solutions to prevent and recover overpayments. The role also serves as a resource and mentor for team members and supports payment-integrity implementations, configurations, quality assurance, and ongoing oversight.

Requirements

High school diploma required.
Three or more years of health care data experience required.
Two or more years of experience participating in health care payer programs, including Medicare, Medicaid, or commercial plans, required.
Two or more years of claims-editing experience with health care payers or claims-editing software vendors required.
Project implementation experience required.

Nice To Haves

Bachelor’s degree preferred.
Certified Coding Specialist, Certified Coding Specialist Physician-Based, or Registered Health Information Administrator certification preferred.

Responsibilities

Review claim payments for accuracy through prepayment edits, audits, contract-compliance reviews, and post-payment payment-integrity solutions.
Support overpayment identification, recovery, remediation, and prevention activities.
Analyze overpayment, refund, and claims data to identify trends, savings opportunities, and potential payment-integrity initiatives.
Develop and support strategies to recover overpayments and establish controls to prevent future payment errors.
Track, analyze, and ensure accurate and timely processing of payment-integrity invoices.
Support retrospective data mining and prospective cost-avoidance initiatives.
Serve as a resource and mentor for team members.
Assist with customization of claims-payment algorithms and edits.
Support vendor implementations, configurations, quality assurance activities, and ongoing oversight.
Coordinate with vendors and internal teams to maintain payment-integrity solutions and improve claims-payment accuracy.
Collaborate with content, technical, and data teams to develop, adjust, validate, and maintain payment-policy edits.
Respond to escalated internal and external inquiries, provider disputes, and payment-integrity research requests.
Monitor vendor file submissions, invoicing, quality metrics, and performance against established expectations.
Identify payment-integrity issues, evaluate evidence and data, and recommend technical or process improvements.
Review health care policies and coding guidance to identify billing and coding rules appropriate for claims-edit development.
Translate policy requirements into specifications for software coding edits and validate that edits function as intended.