Payment Integrity Analyst

The Payment Integrity Analyst is a critical role within our operations, focused on ensuring every claim is paid accurately and compliantly, which directly impacts our clients’ financial health and our members’ trust. You will support the Payment Integrity team, developing professional expertise in medical coding, reimbursement rules, and data analysis to proactively detect, prevent, and resolve payment inaccuracies across our health plan claims. This role requires moving beyond simple auditing—it requires supporting the translation of complex policy into technical system requirements, working in close collaboration with our Product and Engineering teams, and the Claims Integrity Manager who you will report to.

• Vendor Management & Tool Implementation
  • Serve as an operational liaison with external Payment Integrity vendors. Support the Coordination of implementation, testing, and ongoing maintenance of vendor-developed edits and reviews within the overall payment integrity stack.
• Policy & Rule Ideation
  • Assist in the research and support the interpretation of federal/state regulations (e.g. CMS), commercial payer policies, and develop expertise in industry-standard coding rules (CPT, ICD-10, HCPCS, NCCI, MUE).
• Business Requirement Translation
  • Document clear, actionable business requirements and system logic (edits, rules) based on translations provided by senior analysts and managers.
• Data-Driven Investigation
  • Utilize analytical tools to identify and document aberrant billing patterns and potential payment error opportunities, and support senior analysts in performing root cause analysis on identified issues.
• Audit & Recovery
  • Support the execution of detailed pre- and post-payment audits, accurately calculate overpayment and underpayment amounts, and prepare comprehensive documentation to support claim recovery efforts and issue resolution.
• Cross-Functional Partnership
  • Collaborate with key internal stakeholders, including Product, Engineering, Claims Operations, and others, to ensure new edits are accurately implemented, tested, and communicated.
• Issue Resolution
  • Act as a point of escalation for complex payment disputes and claim inquiries, providing definitive analysis and support for the Payment Integrity team.
• Process Excellence
  • Support continuous improvement efforts within the Payment Integrity workflow, focusing on streamlining processes, increasing automation, and enhancing overall claim accuracy.

• 2+ years of relevant experience in healthcare claims auditing, payment integrity, or complex claims processing/adjudication, ideally within a payer or TPA setting.
• Medical coding certification is Preferred (e.g., CPC, COC, or CIC from AAPC, or CCS from AHIMA), or the candidate is Required to obtain it within the first year of employment if they possess comparable experience.
• Experience working directly with external Payment Integrity or FWA vendors to develop, deploy, and manage claim editing capabilities or similar experience.
• Demonstrated proficiency in leveraging data to solve business problems, with hands-on experience in SQL or other database skills (e.g., Looker) for retrieving and analyzing data against large claims datasets.
• Strong, practical knowledge of healthcare reimbursement methodologies (e.g., RBRVS, DRG, fee schedules) and the end-to-end claims lifecycle.
• Experience handling cross-functional projects at a small to mid-sized organization
• Ability to handle multiple tasks/projects under tight deadlines
• Strong internal & external communication
• Working in a highly matrixed environment

• Experience in a process improvement methodology (e.g., Lean Six Sigma, Six Sigma).
• Familiarity with data visualization tools (e.g., Looker, Tableau, Power BI) and/or leveraging AI for process optimization/automation.
• Bachelor’s degree in Healthcare Administration, Finance, Business, or a related quantitative field.
• Project Management
• Experience working with medical healthcare insurance carriers

This is a hybrid position based out of one of our offices: Plano, TX, or Lehi, UT. Hybrid employees are expected to be in the office three days per week (Plano, TX) or two days per week (Lehi, UT).#LI-hybrid 

The actual pay rate offered within the range will depend on factors including geographic location, qualifications, experience, and internal equity. In addition to the hourly rate, you will be eligible for 10,000 stock options and benefits like health insurance, 401k, and paid time off. Learn more about our benefits at https://jobs.collectivehealth.com/benefits/.