Payment Integrity Analyst

JOB PURPOSE

A Payment Integrity Analyst reviews healthcare claims, payments, and billing to find errors, fraud, waste, or abuse, ensuring compliance with rules (like CMS) and policies, using strong data analysis, medical coding (CPT/ICD-10), and auditing skills to prevent financial loss and improve accuracy, often working with vendors and internal teams. Key duties include auditing claims, investigating anomalies, analyzing data for trends, collaborating on billing edits, and preparing reports to support cost containment for health plans.

• Review and audit healthcare claims to identify payment errors, over payments, underpayments, fraud, waste, and abuse (FWA).
• Ensure compliance with CMS regulations, state and federal guidelines, health plan policies, and provider contract terms.
• Analyze medical records, itemized bills, and claim data to validate coding accuracy and medical necessity.
• Apply CPT, HCPCS, ICD-10-CM/PCS, and modifier guidelines to validate correct reimbursement.
• Identify trends, patterns, and anomalies through data analysis to support cost containment initiatives.
• Perform detailed reviews of high-dollar and complex claims to ensure payment accuracy, contract compliance, and medical necessity prior to or after payment.
• Investigate potential payment integrity issues, including duplicate payments, unbundling, upcoding, and incorrect modifiers.
• Collaborate with internal teams (Claims, Configuration, Provider Relations, Compliance, Legal, Analytics, Medical Management) to resolve findings.
• Work closely with internal and external vendors to review audit findings, validate recoveries, and implement corrective actions.
• Prepare detailed audit documentation, summaries, and reports for leadership, compliance, and recovery tracking.
• Present audit findings and recommendations to stakeholders in a clear and professional manner.
• Monitor and track audit outcomes, recoveries, and key performance indicators (KPIs).
• Participate in continuous process improvement initiatives to enhance payment accuracy and efficiency.
• Stay current with regulatory updates, coding changes, CMS guidance, and industry best practices.
• Support internal and external audits, regulatory requests, and compliance reviews as needed.
• Maintain regular and predictable attendance.
• Consistently demonstrate compliance with HIPAA regulations, professional conduct, and ethical practice.
• Work to encourage and promote company culture throughout the organization.
• Other duties as may be assigned.

• High School Diploma or GED required.
• Associates or Bachelor's degree preferred.
• A minimum of three years’ experience in claims processing required, must include Professional and Institutional processing; previous experience in medical billing and coding required if no claims processing experience.
• Knowledge of ICD-10, CPT4, DRG, HCPCS codes, medical terminology, EDI and HIPAA protocols preferred.
• Knowledge of UB and HCFA 1500 forms.
• Experience with Word and Excel.
• Experience with SQL reporting is preferred.

Prolonged periods of sitting at a desk and working on a computer. Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day responsibilities. Must be able to drive a vehicle and daytime/overnight travel as required.

• 401K (4% Match, Immediate Vesting)
• Accident insurance
• Competitive salary
• Critical Illness Insurance
• Dental Insurance
• Employee Assistance Program
• Flexible Spending Account
• Health & Wellness Program
• Health Savings Account
• Life & AD&D Insurance
• Long Term Disability
• Medical Insurance
• Paid Time Off
• Pet Insurance
• Short Term Disability
• Vision Insurance

Health One is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, disability, sex, age, ethnic or national origin, marital status, sexual orientation, gender identity or presentation, pregnancy, genetics, veteran status, or any other status protected by state or federal law.