Senior Payment Integrity Analyst

Inland Empire Health Plan•Rancho Cucamonga, CA

1d•$91,250 - $120,910•Remote

About The Position

Reporting to the Manager, Payment Integrity Operations, the Senior Payment Integrity Analyst provides lead level analyst support to a team of Payment Integrity Analysts on daily operations of vendor(s) and internal programs for Payment Integrity. The incumbent provides quality assurance of junior analysts’ work and action on remediation plans to develop cost avoidance opportunities. This position leads the reporting and tracking of all vendor activity to provide daily and monthly reporting to management. The incumbent partners with leaders and functional representatives to drive health plan financial performance through evaluation and execution of operational initiatives tied to payment integrity (PI) and provider claims accuracy. The Senior Payment Integrity Analyst makes recommendations that inform decisions which contribute to health plan strategy, and acts as a trusted voice in assessing and assisting resolution of complex business challenges that impact cost-containment and regulatory compliance. Commitment to Quality: 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 five (5) years of experience in a combination of payment integrity, claims auditing, and/or medical coding required
Strong data analysis/queries experience
Experience with contract and Division of Financial Responsibility (DOFR) interpretation
Bachelor’s degree in business, health administration, 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 knowledge and deep understanding of: Billing regulations (CMS, HIPAA), DRG, ICD-10, and CPT coding
Medical coding (CPT, ICD-10, HCPCS) and health insurance contracts
The full claims lifecycle, including share of cost and coordination of benefits
Medicaid/Medi-Cal or Medicare regulatory frameworks
Payment integrity concepts (pre-pay audit, post-pay audit types, DRG validation, coordination of benefits and comparable concepts)
Data file layouts and system configurations to troubleshoot and coordinate remediation efforts with IT and vendors
Strong analytical skills with the ability to analyze large datasets and identify patterns
Strong proficiency in SQL, data visualization tools, and MS Excel
Strong written and verbal communication skills, including ability to synthesize complex information
Proven ability to: Analyze data to inform business decisions
Work independently and apply business judgment in a highly regulated, cross-functional environment

Nice To Haves

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

Responsibilities

Lead efforts to improve claim payment accuracy and financial performance.
Review pre- and post-pay claims to identify overpayments, underpayments, and billing inaccuracies.
Develop and refine complex audit data mining techniques to detect irregularities, billing trends, and potential Fraud, Waste, and Abuse (FWA) and translate insights into actionable remediation strategies.
Analyze large datasets using tools (SQL, Excel) to identify trends, anomalies, and root causes of payment errors.
Design and maintain dashboards, trend analyses, and audit tracking tools to provide insight into payment error patterns, vendor performance, and program effectiveness.
Work with providers to resolve payment discrepancies and defend or challenge reimbursement decisions.
Conduct comprehensive reviews of inpatient/outpatient claims, itemized bills, and DRGs (Diagnosis-Related Groups) to identify improper payments.
Serve as a subject-matter expert for complex CMS/DHCS regulatory interpretation and operational application into PI audit strategies, system edits, and business rules.
Provide training, coaching, and QC (quality control) support to junior analysts to ensure accurate work.
Oversee vendor audit pipelines, validate findings, monitor performance metrics, generate financial impact reports, and ensure audit methodologies align with contractual and regulatory standards.
Interpret and apply federal/state regulations (CMS) and provider contract terms for audits.
Ensure regulatory requirements are met for pre-pay edits, post-payment datamining, and overpayment recovery.
Collaborate with leadership in the development of new audit concepts, test system edits, and collaborate on initiatives to reduce financial leakage.
Analyze and resolve provider inquiries and appeals regarding payment adjustments.
Prepare comprehensive appeal defense packages, analyze overturn trends, and recommend process improvements to strengthen audit defensibility.
Perform any other duties as required to ensure Health Plan operations and department business needs are successful.