Role Overview
As a Senior Analyst in Payment Integrity, you will play a key role in identifying, analyzing, and resolving issues within the claims lifecycle. Your expertise in medical coding, reimbursement policies, and claims data will help shape improvements across internal processes and vendor interactions. You'll work closely with cross-functional teams to investigate adverse claim outcomes, refine policy language, and implement changes that enhance accuracy and efficiency.
Key Responsibilities
- Serve as a technical resource on reimbursement rules, internal claim edits, and third-party vendor logic, ensuring alignment with current policies and industry standards.
- Respond to inquiries and disputes from internal teams and external partners, providing clear explanations and data-backed resolutions.
- Analyze medical coding guidelines and industry practices to inform updates to payment integrity policies and system logic.
- Identify opportunities to reduce improper payments by translating data insights into actionable business requirements.
- Collaborate with stakeholders to assess, prioritize, and resolve systemic claim processing issues using root cause analysis.
- Monitor operational trends through data mining and process reviews to proactively address recurring challenges.
- Communicate progress, blockers, and outcomes transparently to maintain alignment across teams.
- Support incident response by delivering timely research, analysis, and recommendations during escalated issues.
- Ensure all activities comply with applicable healthcare regulations and organizational standards.
Qualifications
Required
- Bachelor’s degree or equivalent experience (4+ years)
- Minimum of 3 years in claims operations, medical coding, auditing, or related field
- At least 3 years of direct experience in medical coding within payment integrity environments
- Active certification from AAPC (CPC, COC) or AHIMA (CCS, RHIT, RHIA)
- Proven understanding of reimbursement models, provider contracts, and claims resolution workflows
- 2+ years analyzing datasets to derive business insights and solve operational problems
- 1+ years improving business processes or workflows
- 1+ years collaborating with internal or external partners to achieve shared goals
Preferred
- 2+ years in technical or process improvement roles such as quality assurance, project management, finance, or industrial engineering
- Training in Lean Six Sigma or similar methodology
- Experience writing and interpreting SQL queries
Technical Environment
This role relies heavily on SQL for data extraction, validation, and analysis to support decision-making and system improvements.
Work Mode
This position is local to one of the following metro areas: Atlanta, Chicago, Dallas, Louisville, Minneapolis, Philadelphia, or Salt Lake City. It is currently fully remote, with a potential shift to a hybrid model centered around the local hub office in the future.
Compensation & Benefits
- Annual salary range: $64,832 – $85,092
- Eligibility for annual performance bonuses
- Unlimited vacation policy
- Comprehensive employee benefits package
Culture & Values
The organization emphasizes transparency, collaboration, and a member-first approach. Team members are expected to foster open communication, share knowledge, and work collectively to improve healthcare outcomes.
