Payment Integrity Analyst

Job not on LinkedIn

🔥 0 minutes ago

🌵 Arizona – Remote

🌵 Arizona – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

🦅 H1B Visa Sponsor

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👻 Ghost score 10%

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Tegria

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2020

💼 Consulting

🏥 Healthcare

⚕️ Healthcare Insurance

Consulting • Healthcare • Healthcare Insurance

Tegria is a global healthcare consulting and services company that partners with provider and payer organizations to advance care, improve performance, and tackle the biggest challenges in healthcare. They offer a range of services including patient access optimization, data analytics, cloud solutions, and revenue cycle transformation to create value and enhance healthcare delivery. Tegria focuses on streamlining operations, fostering innovation, and leveraging technology to maximize performance and improve patient experiences.

📋 Description

• Analyze medical, behavioral health, and ancillary claims to identify payment inaccuracies, overpayments, underpayments, and billing irregularities • Perform pre-payment and post-payment claim reviews for adherence to benefit plans, provider contracts, reimbursement methodologies, and regulations • Investigate duplicate claims, unbundling, upcoding, incorrect coding, coordination of benefits, and provider billing discrepancies • Research and document root causes of payment errors and recommend corrective actions • Utilize the TriZetto Facets claims processing platform to analyze claims transactions, benefit plans, provider contracts, and payment outcomes • Review claim adjudication logic and identify configuration issues affecting payment accuracy • Partner with Configuration and IT teams to validate system changes, enhancements, and payment integrity initiatives • Support testing and quality assurance for Facets enhancements, benefit updates, and reimbursement changes • Identify and quantify overpayment recovery opportunities • Coordinate with recovery vendors and internal teams on recovery efforts and track results • Monitor payment integrity savings and recovery performance metrics • Develop strategies to reduce future payment errors and improve first-pass claims accuracy • Develop and maintain reports, dashboards, and trend analyses • Analyze large data sets to identify payment patterns, emerging risks, and cost-saving opportunities • Present findings and recommendations to leadership and stakeholders • Track KPIs including recoveries, savings, claim accuracy, and audit outcomes • Ensure compliance with CMS, state, federal, and health plan regulations • Collaborate with Claims, Provider Relations, Utilization Management, Finance, Compliance, and Vendor partners • Participate in internal and external audits • Support special projects and process improvement initiatives

🎯 Requirements

• Bachelor's degree in Healthcare Administration, Business, Finance, Information Systems, or related field; equivalent experience may be considered • 3+ years of experience in health plan claims operations, payment integrity, claims auditing, or healthcare reimbursement • Hands-on experience with the TriZetto Facets platform • Strong knowledge of healthcare claims processing, provider reimbursement methodologies, and benefit plan structures • Experience analyzing medical claims data and payment outcomes • Proficiency with Microsoft Excel, including advanced formulas, pivot tables, and data analysis • Strong analytical, problem-solving, and investigative skills • Excellent written and verbal communication skills • Experience with Medicare, Medicaid, and Commercial health plans • Knowledge of ICD-10, CPT, HCPCS, DRG, and revenue codes • Experience with payment integrity vendors and recovery programs • SQL, SAS, Power BI, Tableau, or other analytics/reporting tools • Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or similar certification • Experience supporting healthcare regulatory audits and compliance initiatives

🏖️ Benefits

• Multiple health and dental plans with nationally recognized networks • Vision benefits • Total wellness program • Employee assistance program for employees and families • Competitive wages • Retirement savings plans • Company-paid disability and life insurance • Pre-tax savings opportunities (HSA and/or FSA) • Professional development offerings • Opportunities for remote work • Generous paid-time-off program • Flexible schedule accommodations