The Role
The Analyst, Payment Integrity conducts research and analysis to support operations, assesses business impact of policies, and recommends process improvements.
Summary Generated by Built In
Job Summary & Responsibilities
- Research and Analysis
- Serve as contact for external vendors and internal departments to support operations and payment integrity activities.
- Research and respond to low to high priority complex internal and external inquiries.
- Analyze and coordinate vendor performance reviews using KPIs (e.g., recovery yield, turnaround time, false positive rates, provider abrasion).
- Coordinate reconciliation of vendor invoices, validating against contractual terms, recoveries, and performance metrics.
- Is proficient at utilizing a variety of resources including but not limited to on-line information files and databases, Medicare/other plan guidelines, plan certificates, provider contracts.
- Update and create CES and Cotiviti pend resolutions.
- Business Analysis & Reporting
- Analyze operational and financial data to identify trends, savings opportunities, and anomalies.
- Assess business impact of new edits and changes in medical reimbursement policies/guidelines.
- Initiate, develop, coordinate and implement cost/benefit analysis of claims processing.
- Develop documentation, including cost/benefit and business impact analysis and recommendations to implement and/or improve claims processing.
- Collaborate with IT and data teams to validate extracts, reconciliations, and vendor reporting feeds.
- Operational & Strategic Alignment
- Recommend process improvements to increase efficiency and results.
- Identification and resolution of issues and trends as a result of researching and responding to implementation requests, problem reports, and inquiries.
- Support cross-functional projects, including audit response, regulatory requests, and enterprise cost-containment strategies.
- Act as SME (subject matter expert) on payment integrity activities, workflow design, and best practices.
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
#LI-Hybrid
Preferred Qualifications- Bachelor's degree or equivalent combination of education and work experience.
- Two years of related work experience.
- Excellent organizational and analytical skills
- Knowledge of regulations and standards: HIPAA, state, and federal regulations, including CMS, NCQA, and state DOI requirements.
- Basic working knowledge of Microsoft Office applications including, but not limited to Word, Powerpoint, Outlook and Excel.
Skills Required
- Bachelor's degree or equivalent combination of education and work experience
- Two years of related work experience
- Understanding of HMSA's business practices, benefit plans, medical and payment policies
- Excellent organizational and analytical skills
- Knowledge of HIPAA, state, and federal regulations
- Basic working knowledge of Microsoft Office applications including Word, Powerpoint, Outlook and Excel
HMSA Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about HMSA and has not been reviewed or approved by HMSA.
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Healthcare Strength — Medical and dental coverage are described as solid, with preventive services and select zero‑cost features adding value in recent plan years. Employer-sponsored plans can have affordable premiums in certain groups and broad access options.
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Retirement Support — A 401(k) with company match and potential discretionary contributions forms a strong component of total rewards. Retirement support complements the core medical and dental package.
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Leave & Time Off Breadth — Paid holidays and PTO that increases with tenure provide meaningful time‑off flexibility. Time‑away benefits scale with service length.
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The Company
What We Do
The Hawaii Medical Service Association (HMSA), an independent licensee of the Blue Cross and Blue Shield Association, is a reliable name in Hawaii health care. Established in 1938, we are the largest and most experienced provider of health care coverage in the state. Over half of Hawaii’s population have chosen HMSA for their health care coverage. We are dedicated to providing quality, affordable health plans; employee benefit services; and worksite wellness programs. HMSA also offers a variety of programs, services and support to help improve the health and well-being of our members and community.
