Payment Integrity Analyst

🕒 6 dias atrás

🏄 California – Remoto

🏄 California – Remote

💵 $80.059 - $106.059 / ano

⏰ Tempo Integral

🟡 Pleno

🟠 Sênior

🧐 Analista

👻 Score fantasma 1%

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IEHP

SiteLinkedInTodas as Vagas

1001 - 5000 funcionários

Fundada em 1995

🛡️ Seguros

💼 Consultoria

📦 Logística

💰 Grant em 2021-02

Insurance • Consulting • Logistics

IEHP é um plano de saúde dedicado a atender indivíduos e famílias de baixa renda nos condados de Riverside e San Bernardino. Eles oferecem uma variedade de programas, incluindo Medi-Cal, DualChoice e Covered California, fornecendo cobertura de saúde para residentes que, de outra forma, não teriam acesso aos serviços médicos necessários. Com foco na saúde holística e no bem-estar comunitário, a IEHP faz parcerias com médicos e instalações locais para garantir um cuidado abrangente para seus membros, apoiando-os com recursos em saúde mental, aulas de ginástica e educação para o bem-estar.

Descrição

• Monitor the overpayment inventory • Analyze claims, coding, contracts, and clinical documentation to identify improper payments • Validate audit findings • Develop remediation recommendations and actions • Leverage data analytics, audit methodologies, and regulatory expertise to detect reimbursement inaccuracies • Support overpayment recovery processes • Mitigate future payment integrity risk • Collaborate with clinical, legal, SIU/FWA, provider relations, and IT teams • Assess patterns of improper spend • Implement sustainable solutions • Maintain audit-ready documentation • Contribute to business rule enhancements • Support operational improvements that strengthen payment accuracy and incremental savings opportunities across the claims lifecycle • Incorporate IEHP’s Quality Program goals, including HEDIS, CAHPS, and NCQA Accreditation

🎯 Requisitos

• A minimum of three (3) years of experience in a combination of healthcare claims processing, billing, and/or auditing functions required • Experience with contract and Division of Financial Responsibility (DOFR) interpretation • Experience with data analysis/queries • Bachelor’s degree in healthcare, finance, 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; this experience is in addition to the minimum years listed in the Experience Requirements above • Certification in RHIA, RHIT, CCS, CPC, CIC or similar certification preferred • Strong understanding of medical coding (CPT, ICD-10, HCPCS) and health insurance contracts • Strong understanding of the full claims lifecycle, including share of cost and coordination of benefits • Strong understanding of Medicaid/Medi-Cal or Medicare regulatory frameworks • Strong understanding of payment integrity concepts, including pre-pay audit, post-pay audit types, DRG validation, coordination of benefits and comparable concepts • Intermediate proficiency in SQL and Microsoft Office Suite (Excel, Access) required • Demonstrated ability to make independent decisions in claim coding and adjudication • Strong analytical, problem-solving, and trend analysis skills • Ability to translate analytical findings into operational recommendations • Solid organizational and planning capabilities • Ability to communicate effectively with internal stakeholders and external parties • Ability to independently prioritize caseloads based on impact and timelines

🏖️ Benefícios

• Competitive salary • State of the art fitness center on-site • Medical Insurance with Dental and Vision • Life, short-term, and long-term disability options • Career advancement opportunities and professional development • Wellness programs that promote a healthy work-life balance • Flexible Spending Account – Health Care/Childcare • CalPERS retirement • 457(b) option with a contribution match • Paid life insurance for employees • Pet care insurance