Payment Integrity Analyst II

Accountabilities:

• • Review, analyze, and complete pre- and post-payment claim audits and appeals in accordance with client policies, CMS guidelines, and healthcare industry standards.
  • Apply clinical judgment to evaluate documentation and determine the appropriateness and accuracy of claims.
  • Interpret and apply payer policies and regulatory requirements across areas such as itemized bills, DRG reviews, and specialty audits.
  • Use relevant systems, tools, and resources to conduct thorough and timely audits, appeals, and payment integrity reviews.
  • Analyze healthcare claims, reimbursement information, and supporting documentation to identify discrepancies and potential payment issues.
  • Communicate audit findings and conclusions clearly and professionally in both written and verbal formats.
  • Manage multiple projects and priorities while meeting established deadlines and quality expectations.
  • Participate in clinical team meetings, company meetings, training sessions, educational opportunities, and other relevant activities.
  • Collaborate effectively with internal stakeholders and interact professionally with clients and senior-level audiences when required.
  • Contribute analytical insights and actionable recommendations that support strategic payment integrity initiatives.
  • Perform additional responsibilities as assigned.

  Requirements:

  • Maintain an active LPN, LVN, and/or RN license.
  • Bring at least 1 year of relevant professional experience or an equivalent combination of education and experience.
  • Have at least 1 year of experience in healthcare revenue cycle and 1 year of hospital bill auditing experience.
  • Demonstrate strong knowledge of claims processing, ICD-10 coding, DRG validation, coordination of benefits, healthcare revenue cycles, and claims reimbursement.
  • Have experience in medical bill auditing and/or clinical environments such as operating rooms, intensive care, emergency care, telemetry, medical/surgical units, obstetrics, geriatrics, or orthopedics.
  • Experience with health insurance denials and appeals, payer or vendor audits, workers' compensation claims, or prospective, concurrent, and retrospective utilization review is preferred.
  • A bachelor's degree in healthcare or a related field is preferred.
  • Demonstrate working knowledge of CMS requirements and commercial payer policies.
  • Be proficient with Microsoft Office, including Pivot Tables and database management.
  • Possess strong analytical, data interpretation, modeling, and complex problem-solving abilities.
  • Demonstrate excellent written and verbal communication skills, interpersonal effectiveness, adaptability, and a results-oriented mindset.
  • Be comfortable managing multiple projects, setting priorities, and working within committed timelines.
  • Show exceptional attention to detail and the ability to perform effectively in a fast-paced, dynamic environment.
  • Be capable of working independently while collaborating effectively with broader clinical and business teams.

  Benefits:

  • Salary range: $66,941–$101,258, with compensation determined by factors including location, experience, qualifications, skills, internal equity, and market conditions.
  • Remote work arrangement.
  • Medical insurance, including HDHP options with pharmacy coverage.
  • Dental and vision insurance.
  • Health Savings Account (HSA) and Flexible Spending Account (FSA) options.
  • Long-term disability and life insurance.
  • Accident and critical illness insurance.
  • 401(k) and Roth 401(k) retirement plans.
  • Paid time off.
  • Pre-paid legal insurance.
  • Parking and transit FSA options.
  • Opportunities for professional development, training, and career advancement.
  • A collaborative environment focused on healthcare payment accuracy, quality, and continuous improvement.