Payment Integrity Analyst

Job not on LinkedIn

🔥 0 minutes ago

🏄 California – Remote

🏄 California – Remote

💵 $80.1k - $106.1k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

👻 Ghost score 1%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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IEHP

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1995

🛡️ Insurance

💼 Consulting

📦 Logistics

💰 Grant on 2021-02

Insurance • Consulting • Logistics

IEHP is a health plan dedicated to serving low-income individuals and families in Riverside and San Bernardino counties. They offer a variety of programs including Medi-Cal, DualChoice, and Covered California, providing healthcare coverage for residents who may not otherwise have access to necessary medical services. With a focus on holistic health and community wellness, IEHP partners with local doctors and facilities to ensure comprehensive care for their members, supporting them with resources in mental health, fitness classes, and wellness education.

📋 Description

• 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

🎯 Requirements

• 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

🏖️ Benefits

• 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