Payment Integrity Analyst
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Job Location:
Monthly Salary:
Posted on:
18 hours ago
Vacancies:
1 Vacancy
Job Summary
At Collective Health were transforming how employers and their people engage with their health benefits by seamlessly integrating cutting-edge technology compassionate service and world-class user experience design.
The Payment Integrity Analyst is a critical role within our operations focused on ensuring every claim is paid accurately and compliantly which directly impacts our clients financial health and our members trust. You will support the Payment Integrity team developing professional expertise in medical coding reimbursement rules and data analysis to proactively detect prevent and resolve payment inaccuracies across our health plan claims. This role requires moving beyond simple auditingit requires supporting the translation of complex policy into technical system requirements working in close collaboration with our Product and Engineering teams and the Claims Integrity Manager who you will report to.
What youll do:
- Vendor Management & Tool Implementation
- Serve as an operational liaison with external Payment Integrity vendors. Support the Coordination of implementation testing and ongoing maintenance of vendor-developed edits and reviews within the overall payment integrity stack.
- Policy & Rule Ideation
- Assist in the research and support the interpretation of federal/state regulations (e.g. CMS) commercial payer policies and develop expertise in industry-standard coding rules (CPT ICD-10 HCPCS NCCI MUE).
- Business Requirement Translation
- Document clear actionable business requirements and system logic (edits rules) based on translations provided by senior analysts and managers.
- Data-Driven Investigation
- Utilize analytical tools to identify and document aberrant billing patterns and potential payment error opportunities and support senior analysts in performing root cause analysis on identified issues.
- Audit & Recovery
- Support the execution of detailed pre- and post-payment audits accurately calculate overpayment and underpayment amounts and prepare comprehensive documentation to support claim recovery efforts and issue resolution.
- Cross-Functional Partnership
- Collaborate with key internal stakeholders including Product Engineering Claims Operations and others to ensure new edits are accurately implemented tested and communicated.
- Issue Resolution
- Act as a point of escalation for complex payment disputes and claim inquiries providing definitive analysis and support for the Payment Integrity team.
- Process Excellence
- Support continuous improvement efforts within the Payment Integrity workflow focusing on streamlining processes increasing automation and enhancing overall claim accuracy.
To be successful in this role youll need:
- 2 years of relevant experience in healthcare claims auditing payment integrity or complex claims processing/adjudication ideally within a payer or TPA setting.
- Medical coding certification is Preferred (e.g. CPC COC or CIC from AAPC or CCS from AHIMA) or the candidate is Required to obtain it within the first year of employment if they possess comparable experience.
- Experience working directly with external Payment Integrity or FWA vendors to develop deploy and manage claim editing capabilities or similar experience.
- Demonstrated proficiency in leveraging data to solve business problems with hands-on experience in SQL or other database skills (e.g. Looker) for retrieving and analyzing data against large claims datasets.
- Strong practical knowledge of healthcare reimbursement methodologies (e.g. RBRVS DRG fee schedules) and the end-to-end claims lifecycle.
- Experience handling cross-functional projects at a small to mid-sized organization
- Ability to handle multiple tasks/projects under tight deadlines
- Strong internal & external communication
- Working in a highly matrixed environment
Nice to have:
- Experience in a process improvement methodology (e.g. Lean Six Sigma Six Sigma).
- Familiarity with data visualization tools (e.g. Looker Tableau Power BI) and/or leveraging AI for process optimization/automation.
- Bachelors degree in Healthcare Administration Finance Business or a related quantitative field.
- Project Management
- Experience working with medical healthcare insurance carriers
Pay Transparency Statement
This is a hybrid position based out of one of our offices: Plano TX or Lehi UT. Hybrid employees are expected to be in the office three days per week (Plano TX) or two days per week (Lehi UT).#LI-hybrid
The actual pay rate offered within the range will depend on factors including geographic location qualifications experience and internal addition to the hourly rate you will be eligible for 10000 stock options and benefits like health insurance 401k and paid time off. Learn more about our benefits athttps:// UT Pay Range
Key Skills
- IDS
- System Design
- Haskell
- PCB
- Root cause Analysis
- Technical Writing
- System Security
- Federal Aviation Regulations
- Warehouse Distribution Experience
- Encryption
- Product Development
- Contracts
About Company
Collective Health offers the first integrated solution that empowers employers to administer plans, manage costs, and take care of their people—all in one place.
