Medical Economics Analyst – Payment Integrity

🕒 vor 17 Tagen

🌶️ New Mexico – Remote

🌶️ New Mexico – Remote

💵 $83.366 - $127.275 / Jahr

⏰ Vollzeit

🟢 Junior

🟡 Mittelstufe

🧐 Analyst

🦅 H1B-Visum-Sponsor

Dieses Unternehmen hat in der Vergangenheit H1B-Visa gesponsert.

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Presbyterian Healthcare Services

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10.000+ Mitarbeiter

Gegründet 1908

⚕️ Krankenversicherung

🤝 Non-Profit

Healthcare Insurance • Non-profit

Presbyterian Healthcare Services ist ein integriertes, gemeinnütziges Gesundheitssystem mit Sitz in New Mexico, das Krankenhäuser, Notfallkliniken, Spezial- und Hausarztpraxen, virtuelle Versorgung (VirtualPRES) und Krankenversicherungspläne betreibt. Die Organisation bietet eine breite Palette klinischer Dienstleistungen an, einschließlich Neurowissenschaften, Transplantation, Krebsbehandlung, Chirurgie, Verhaltensmedizin und häusliche Pflege. Zudem werden Gesundheitsprogramme für die Gemeinschaft und wohltätige Projekte (finanzielle Unterstützung, Gemeindehilfe und Partnerschaften mit der medizinischen Ausbildung) durchgeführt. Es werden individuelle, Medicaid, Medicare Advantage und Arbeitgeberkrankenversicherungen sowie Patientenwerkzeuge (MyChart/myPRES), Unterstützung bei Abrechnungen und ein Engagement für Zugang und Qualität im gesamten Bundesstaat angeboten.

Beschreibung

• 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

🎯 Anforderungen

• 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.

🏖️ Vorteile

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