Payment Integrity Operations Analyst - Remote AZ

Blue Cross Blue Shield of Arizona•Phoenix, AZ

2d•Remote

About The Position

The Payment Integrity Operations Analyst is responsible for supporting payment accuracy and operational effectiveness across the healthcare claims lifecycle, from intake and adjudication through post-payment review, recovery, and provider/member resolution. This role partners closely with Claims Operations, Payment Integrity, Analytics, Clinical/Coding SMEs, and Technology teams to identify claim processing issues, payment risks, and rework opportunities. The analyst applies deep claims knowledge to analyze workflows, validate outcomes, support audits and recoveries, and drive sustainable improvements that reduce provider abrasion, improve member experience, and protect plan assets.

Requirements

4 years of experience in healthcare operations with a strong focus on claims processing, payment integrity, or claims analysis (Level I)
6 years of experience in healthcare operations with a strong focus on claims processing, payment integrity, or claims analysis (Level II)
8 years of experience in healthcare operations with a strong focus on claims processing, payment integrity, or claims analysis (Level III)
Demonstrated experience across the full claim’s lifecycle within a healthcare payer environment (All Levels)
Experience analyzing claims data, identifying payment issues, and supporting operational or audit-driven resolutions (All Levels)
High-School Diploma or GED in general field of study (All Levels)
Extensive knowledge of the health insurance industry
Advanced claims and enrollment process and system knowledge
Excellent problem-solving and investigative skills
Excellent relationship building and communication skills
Strong skills in influencing others across teams
Strong written and verbal communication
Strong understanding of healthcare payer claims processes and adjudication logic
Analytical skills with the ability to interpret claims, audit findings, and operational metrics
Working knowledge of medical terminology, coding concepts (ICD‑10, CPT, HCPCS, DRGs), and reimbursement methodologies
Proficiency with Excel and claims or reporting systems
The ability to communicate at all levels, the role will require the analyst to be able to communicate effectively with operations users, a peer network of stakeholders, senior executives, technical resources as well as vendor partners.
Analytical skills to support independent and effective decisions
Knowledge of internal departments and operations
Prioritize tasks and work with multiple priorities, sometimes under limited time constraints.
Perseverance in the face of resistance or setbacks.
Creative judgment and ability to think strategically.
Conceptual and tactical planning skills.
Effective interpersonal skills and ability to maintain positive working relationship with others.
Verbal and written communication skills and the ability to interact professionally with a diverse group, executives, managers, and subject matter experts.
Systems research and analysis.
Ability to write and present business documentation.
Extensive experience and judgment necessary to plan and accomplish goals.
Experience gaining trust of indirect subordinate staff as well as organizational counterparts to achieve results.
Facilitate and resolve customer requests and inquiries for all levels of management within the Corporation.
Ability to help others navigate both ambiguous and highly complex system concepts and fostering discussion and problem solving that maintains a focus on customer experience.
Build synergy with a diverse team in an ever changing environment.
Experience with synthesizing detailed system information and processes to Executive leadership, both verbally and written, in a fashion that is relatable and accessible by non-technical minds.

Nice To Haves

Experience in payment integrity, claims auditing, coding support, or recovery operations
Experience working with claims adjudication systems, enrollment systems, or payment integrity vendors
Exposure to process improvement, rework operations, or system enhancement initiatives
Associate’s or Bachelor’s Degree in Business, Healthcare Administration, Information Systems, or related field (Level II-III)
CPC, CIC, CCS, or similar coding or payment integrity–related credentials (Level II)
Lean Six Sigma White/Yellow Belt (Level II-III)
Advanced skill in use of office equipment, including copiers, fax machines, scanner and telephones
Advanced PC proficiency
Advanced proficiency in spreadsheet, database and word processing software
Advanced systems research and analysis expertise
Work with ambiguous and conflicting information while keeping focused on the end goal
Solid technical ability and problem solving skills
Strong technical documentation skills and a strong ability to translate technical concepts so that they are easily understood by non-technical stakeholders
Ability to provide mentoring and technical coaching to indirect subordinates and peers

Responsibilities

Analyze claims processing workflows to identify payment risks, rework drivers, and systemic defects across all lines of business.
Support or lead claims rework and adjustment activities, ensuring accurate resolution and timely completion.
Communicate complex claims and payment integrity topics clearly to both technical and non-technical stakeholders.
Serve as a subject matter resource for claims lifecycle impacts related to system changes, vendor outputs, and operational enhancements.
Analyze claims and audit data to identify trends, outliers, and root causes driving incorrect payment or rework.
Partner with analytics teams to define reporting requirements and validate outputs used for payment integrity and operational decision-making.
Translate complex claims and system findings into clear business insights for operational and leadership audiences.
Participate in future-state process design and workflow optimization initiatives.
Identify opportunities to improve auto-adjudication, reduce manual touchpoints, and strengthen controls within the claims lifecycle.
Lead enterprise-impact operational analyses and cross-functional initiatives that materially improve claims accuracy, payment integrity outcomes, and provider/member experience.
Set analytical direction for complex problem statements; designs measurement approaches, defines success metrics (quality, financial, timeliness), and ensures insights translate into decisions and sustainable operational controls.
Build and validate advanced analyses (e.g., segmentation, trending, variance drivers, root-cause hypotheses) and partners with Analytics/IT to improve data quality, automate reporting, and enable self-service operational insights.
Define the analytical approach, build credible conclusions from messy/complex data and help drive decisions.
Drive advanced operational efficiency by identifying and eliminating high-cost manual touchpoints, strengthening upstream adjudication controls.
Lead end-to-end process improvement work (problem definition, current-state mapping, root-cause, future-state design, and implementation); develops DLPs/training and partners with stakeholders to drive adoption and measurable outcomes.
Apply advanced critical thinking to ambiguous, high-risk issues by synthesizing policy/contract/system behavior, evaluating competing options, anticipating downstream impacts, and recommending the best path with mitigation plans.
Provide thought leadership and coaching across Payment Integrity and Claims Operations; influences leaders and peers through clear recommendations, risk tradeoffs, and executive-ready communication.
Support pre- and post-payment payment integrity activities, including claim selection logic, audit validation, adjustments, and recovery coordination.
Review claims, remittances, contracts, policies, and supporting documentation to validate adjudication accuracy and compliance.
Act as a liaison between Claims Operations, Payment Integrity, Coding, Clinical, IT, and external vendors.
Represent Payment Integrity operational needs in cross-functional forums, backlog prioritization, and system enhancement discussions.
Advance the Rework culture towards one of accountability, collaboration, results-orientation, and most importantly customer centricity.
Provide in depth rework knowledge to staff in order to strengthen and refine the knowledge within the team.
Maintain effective working relationships to ensure teamwork in achieving corporate goals.