Payment Integrity Analyst

About You You are a person who loves to identify discrepancies, prevent overpayments, and ensure adherence to regulatory, contractual, and coding guidelines. We need someone who has expertise in medical coding, reimbursement methodologies, and healthcare policy and can apply that expertise to develop, implement, and maintain claims editing rules and audit processes. In the role of Payment Integrity Analyst, you will be responsible for ensuring the accuracy and compliance of healthcare claim payments across commercial, Medicare, and Medicaid lines of business. Tell us about your experience in Payment Integrity. Are you a team player and a self-motivator? What is your experience with conducting business in a way that is credit to a company? We are counting on you to manage multiple projects using your problem-solving skills. We are looking for someone UNCOMMON. What is uncommon about you? Are you highly committed? Are you team-oriented? Do you value professionalism, trust, honesty, and integrity? If so, we cannot wait to meet you. About The Position 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 Translate complex regulatory and reimbursement policies into system specifications Oversee testing, validation, and implementation of editing rules Conduct root cause analysis and recommend systemic solutions Monitor CMS, OIG, and regulatory updates; ensure organizational compliance Act as SME for coding, billing, and payment integrity methodologies Mentor junior analysts and provide technical guidance Collaborate with IT, policy, and leadership teams on strategic initiatives Support benefit configuration and optimization in platforms like TriZetto Facets Present findings, insights, and recommendations to leadership Claims Review & Audit Perform pre-pay and post-pay reviews of medical claims for accuracy, medical necessity, and compliance Identify billing errors including duplicate claims, unbundling, upcoding, and modifier misuse Ensure alignment with Tricare and VA Policy, CMS, state regulations, and payer-specific policies Payment Integrity & Recovery Detect and quantify overpayments and support recovery efforts Analyze claim patterns to identify systemic issues and cost-saving opportunities Partner with recovery vendors and internal teams to resolve discrepancies Policy & Rule Development Interpret healthcare policies (Tricare/VA Policy, CMS manuals, NCCI edits, LCDs/NCDs, fee schedules) Translate regulatory and coding guidance into automated claims editing logic Define rule specifications, decision pathways, and acceptance criteria Support configuration and optimization of claims editing platforms (e.g., Optum CES, TriZetto Facets) Data Analysis & Validation Analyze large datasets to identify trends, anomalies, and root causes of payment errors Develop SQL queries and reports to support audit findings and rule validation Perform testing and validation of editing rules and system configurations Regulatory Monitoring & Compliance Monitor updates from Tricare and VA Policy, CMS, OIG, and industry sources for regulatory changes Maintain compliance with federal and state healthcare laws and reimbursement policies Support development and maintenance of medical policies and procedures Collaboration & Communication Work cross-functionally with claims, IT, clinical, compliance, and Client Policy teams Serve as a subject matter expert (SME) on coding, billing, and payment integrity issues Communicate findings, policy interpretations, and recommendations to stakeholders Minimum Requirements 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) Advanced SQL and data analysis skills Demonstrated experience in rule development and system configuration Experience with Tricare and Veterans Administration, Medicare, Medicaid, and/or commercial reimbursement methodologies Hands-on experience with claims adjudication and editing systems Strong knowledg