Sr Payment Integrity Analyst

Position Summary:

Community Care Plan is seeking an experienced Senior Payment Integrity Analyst to join our team. This role will serve as the business lead for payment integrity activities across our Medicaid and Marketplace lines of business. The role will lead encounter-related business activities and serve as the primary liaison between Finance, IT, Compliance, Claims and Quality.

The role will oversee enterprise-wide payment integrity strategies designed to prevent, detect, and recover improper medical claims. The role will develop and manage pre- and post-payment cost-containment programs, select and monitor vendor performance, and ensure payment integrity activities comply with applicable federal and state regulatory requirements. The role will also collaborate with Risk Adjustment and external partners to support payment integrity initiatives, encounter-related activities, data accuracy, and other cost-containment efforts.
 

Essential Duties and Responsibilities:

The role will be responsible for the following:

• Direct enterprise-wide strategy to prevent, detect, and recover improper medical claims.
• Oversee cost-containment programs and ensure the company complies with federal and state regulatory mandates.
• Evaluate and manage vendors related to payment integrity.
• Design and implement strategies to identify and correct errors in contract configuration.
• Ensure claims are processed accurately in accordance with all contractual and state and federally required updates and terms.
• Design and implement comprehensive strategies to review claims both before and after they are paid (both pre-payment and post-payment reviews).
• Oversee the implementation of clinical and non-clinical claim editing systems or modules (e.g., duplicate detection, upcoding, and unbundling limits).
• Communicate regularly with Compliance, Claims, Finance, and IT.
• Perform root cause analysis on contract configuration errors and work cross-functionally with Claims, IT, Provider Operations, and various partners in care to implement corrections.
• Document standard operating procedures (SOPs) and maintain up-to-date process guides.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Qualifications: 

Required:

• Bachelor’s degree in Healthcare, Finance, or a related field, or five (5) or more years of relevant work experience.
• Minimum of 5 years of experience in a data-related role within a health plan, preferably with claims and encounter data.
• Prior experience with payment integrity within a Managed Medicaid health plan preferably in Florida.
• Strong knowledge of SQL and Power BI.

Preferred:

• Experience with payment integrity within Marketplace or commercial lines of business.
• Experience working with claims and encounter data and processes within a health plan.

Skills and Abilities:

• Ability to summarize, analyze, and clearly articulate data and findings.
• Strong organizational and project management skills, with the ability to prioritize tasks, meet deadlines, and coordinate cross-functional initiatives.
• Ability to assess and manage risks associated with health insurance products and apply appropriate risk mitigation strategies.
• Strong written and verbal communication skills, with the ability to clearly convey complex technical information to non-technical stakeholders, including senior management, regulators, and business partners.
• Ability to identify challenges, evaluate potential solutions, and develop effective approaches to complex problems.

Work Schedule:

Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs.

Physical Demands: 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee may occasionally be required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

Work Environment: 

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion.

Background Screening Notice:

In compliance with Florida law, candidates selected for this position must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse.

The Clearinghouse is a statewide system managed by the Agency for Health Care Administration (AHCA) and is designed to help protect children, seniors, and other vulnerable populations while streamlining the screening process for employers and applicants.

Additional information is available at: https://info.flclearinghouse.com