Payment Integrity Analyst

Job Summary

To ensure the accuracy and compliance of healthcare claim payments across commercial, Medicare, and Medicaid lines of business, the full-time Payment Integrity Analyst will lead complex claim audits, develop claims editing rules, and monitor regulatory changes while working remotely.

Key responsibilities

• Lead complex claim audits and investigations involving high-risk or high-value claims
• Design, develop, and maintain advanced claims editing rules and logic
• Monitor CMS, OIG, and regulatory updates to ensure organizational compliance

Required qualifications

• Associate's or Bachelor's degree in Health Administration, Public Health, Business, or related field (or equivalent experience)
• 5+ years of experience in healthcare claims, payment integrity, auditing, or revenue cycle
• Advanced expertise in coding systems, reimbursement methodologies, and CMS regulations
• Strong experience with claims editing platforms (e.g., Optum CES) and advanced SQL skills
• Certifications such as CPC, CCS/CCS-P, or RHIT/RHIA are preferred