Payment Integrity Analyst

Signature Performance, Inc.

About The Position

The Payment Integrity Analyst is responsible for ensuring the accuracy and compliance of healthcare claim payments across commercial, Medicare, and Medicaid lines of business. This role involves identifying discrepancies, preventing overpayments, and ensuring adherence to regulatory, contractual, and coding guidelines. The analyst will apply expertise in medical coding, reimbursement methodologies, and healthcare policy to develop, implement, and maintain claims editing rules and audit processes. Key responsibilities include leading complex claim audits, designing and maintaining claims editing rules, translating policies into system specifications, overseeing testing and validation, conducting root cause analysis, monitoring regulatory updates, and serving as a subject matter expert. The role also involves collaborating with various teams, supporting benefit configuration, and presenting findings to leadership.

Requirements

Associate's or Bachelor's degree in Health Administration, Public Health, Business, or related field (or equivalent experience)
5+ years of experience in healthcare claims, payment integrity, auditing, or revenue cycle
Advanced expertise in coding systems, reimbursement methodologies, and CMS regulations
Strong experience with claims editing platforms (e.g., Optum CES)
Advanced SQL and data analysis skills
Demonstrated experience in rule development and system configuration
Experience with Tricare and Veterans Administration, Medicare, Medicaid, and/or commercial reimbursement methodologies
Hands-on experience with claims adjudication and editing systems
Strong knowledge of CPT, HCPCS, ICD-10 coding systems
Strong knowledge of NCCI edits and CMS guidelines
Proficiency in SQL and data analysis
Proficiency in Excel (pivot tables, VLOOKUP, data manipulation)
Experience with EDI transactions, CMS-1500, and claims workflows
CPC (Certified Professional Coder)
CCS / CCS-P (Certified Coding Specialist)
RHIT / RHIA
Strategic thinking
Leadership and mentorship
Advanced analytical and technical skills
Deep regulatory and policy expertise
Strong decision-making and problem-solving ability
U.S. Citizenship or naturalized citizenship is required for this position.
All work on all positions at Signature Performance must be completed in the continental United States, Alaska, or Hawaii.

Nice To Haves

Team player and a self-motivator
Experience conducting business in a way that is credit to a company
Ability to manage multiple projects using problem-solving skills
Uncommon qualities

Responsibilities

Lead complex claim audits and investigations involving high-risk or high-value claims
Design, develop, and maintain advanced claims editing rules and logic
Translate complex regulatory and reimbursement policies into system specifications
Oversee testing, validation, and implementation of editing rules
Conduct root cause analysis and recommend systemic solutions
Monitor CMS, OIG, and regulatory updates; ensure organizational compliance
Act as SME for coding, billing, and payment integrity methodologies
Mentor junior analysts and provide technical guidance
Collaborate with IT, policy, and leadership teams on strategic initiatives
Support benefit configuration and optimization in platforms like TriZetto Facets
Present findings, insights, and recommendations to leadership
Perform pre-pay and post-pay reviews of medical claims for accuracy, medical necessity, and compliance
Identify billing errors including duplicate claims, unbundling, upcoding, and modifier misuse
Ensure alignment with Tricare and VA Policy, CMS, state regulations, and payer-specific policies
Detect and quantify overpayments and support recovery efforts
Analyze claim patterns to identify systemic issues and cost-saving opportunities
Partner with recovery vendors and internal teams to resolve discrepancies
Interpret healthcare policies (Tricare/VA Policy, CMS manuals, NCCI edits, LCDs/NCDs, fee schedules)
Translate regulatory and coding guidance into automated claims editing logic
Define rule specifications, decision pathways, and acceptance criteria
Support configuration and optimization of claims editing platforms (e.g., Optum CES, TriZetto Facets)
Analyze large datasets to identify trends, anomalies, and root causes of payment errors
Develop SQL queries and reports to support audit findings and rule validation
Perform testing and validation of editing rules and system configurations
Monitor updates from Tricare and VA Policy, CMS, OIG, and industry sources for regulatory changes
Maintain compliance with federal and state healthcare laws and reimbursement policies
Support development and maintenance of medical policies and procedures
Work cross-functionally with claims, IT, clinical, compliance, and Client Policy teams
Serve as a subject matter expert (SME) on coding, billing, and payment integrity issues
Communicate findings, policy interpretations, and recommendations to stakeholders