Medical Economics Analyst – Payment Integrity

🕒 Maio 26

🌶️ New Mexico – Remoto

🌶️ New Mexico – Remote

💵 $83.366 - $127.275 / ano

⏰ Tempo Integral

🟢 Júnior

🟡 Pleno

🧐 Analista

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Presbyterian Healthcare Services

SiteLinkedInTodas as Vagas

10.000+ funcionários

Fundada em 1908

⚕️ Seguro de Saúde

🤝 Sem Fins Lucrativos

Healthcare Insurance • Non-profit

A Presbyterian Healthcare Services é um sistema de saúde integrado e sem fins lucrativos, baseado no Novo México, que opera hospitais, clínicas de atendimento urgente, práticas especializadas e de cuidados primários, atendimento virtual (VirtualPRES) e planos de saúde. A organização oferece uma ampla gama de serviços clínicos — incluindo neurociência, transplantes, tratamento de câncer, cirurgia, saúde comportamental e cuidados domiciliares — além de conduzir programas de saúde comunitária e de caridade (assistência financeira, apoio comunitário e parcerias com educação médica). Oferece planos de saúde individuais, Medicaid, Medicare Advantage e para empregadores, além de ferramentas para pacientes (MyChart/myPRES), suporte para faturamento, e compromisso com o acesso e qualidade em todo o estado.

Descrição

• The Payment Integrity Medical Economics Analyst plays a critical role in identifying, quantifying, and validating medical cost savings opportunities through deep partnership with the Payment Integrity team. • This role combines advanced analytics, claims validation, and financial insight to ensure accuracy of payments, integrity of savings initiatives, and alignment to total cost of care (TCOC) objectives. • This individual will leverage enterprise data assets, including claims and provider data, to produce actionable insights, validate recoveries, and support pre- and post-pay integrity initiatives. • Partner closely with Payment Integrity, Operations, and vendor partners (e.g., Cotiviti, Optum) to support pre-pay and post-pay initiatives • Analyze claims data to identify patterns of overpayment, billing anomalies, and coding discrepancies • Support development and refinement of rules, algorithms, and audit strategies to improve payment accuracy • Translate operational PI activities into measurable financial outcomes tied to TCOC • Validate identified savings opportunities through detailed claims-level analysis and audit review • Develop and maintain methodologies to quantify gross and net savings (pre-pay edits, post-pay recoveries, avoidance) • Perform before/after and control group analyses to ensure credibility of savings estimates • Partner with finance to align validated savings with general ledger and financial reporting • Extract, transform, and analyze large-scale healthcare datasets using SQL, SAS, or similar tools • Work within enterprise data warehouse environments to build repeatable datasets and analytic pipelines • Develop dashboards and reporting tools to monitor payment integrity performance and trends • Support integration of external/vendor outputs into internal analytics frameworks • Produce clear, concise reporting on payment integrity performance, savings, and emerging opportunities • Develop executive-ready summaries highlighting key drivers, risks, and recommended actions • Support ongoing monitoring of initiative performance and identification of new opportunities • Generate pre-payment edit contribution invoices for Self-Funded accounts

🎯 Requisitos

• Bachelor’s degree in Actuarial Science, Economics, Finance, Data Analytics, Healthcare Administration, or related field (or equivalent experience) • 2–5+ years of experience in healthcare analytics, medical economics, or payment integrity • Strong technical skills in SQL and/or SAS (required); • Experience querying large relational databases • Experience working with claims data and reimbursement methodologies (fee schedules, IPPS, OPPS) • Demonstrated ability to perform financial and statistical analysis on large datasets • Strong problem-solving skills with attention to detail and data accuracy.

🏖️ Benefícios

• medical • dental • vision • short-term and long-term disability • group term life insurance • optional voluntary benefits • wellness program