Sr Payment Integrity Analyst
HybridSunrise, Florida, United States
Job Summary
Direct enterprise-wide strategy to prevent, detect, and recover improper medical claims across Medicaid and Marketplace lines. Oversee cost-containment programs, manage vendor performance, and implement pre- and post-payment review strategies to ensure accurate claim processing. Design and deploy clinical and non-clinical claim editing systems for duplicate detection, upcoding, and unbundling limits. Perform root cause analysis on contract configuration errors, document standard operating procedures, and maintain regulatory compliance with federal and state mandates. Collaborate regularly with Compliance, Claims, Finance, IT, and external partners to execute payment integrity initiatives.
Required Qualifications
- Bachelor's degree in Healthcare, Finance, or a related field
- five (5) or more years of relevant work experience
- Minimum of 5 years of experience in a data-related role within a health plan
- experience with claims and encounter data
- Prior experience with payment integrity within a Managed Medicaid health plan
- experience in Florida
- Strong knowledge of SQL
- Strong knowledge of Power BI
- Ability to summarize, analyze, and clearly articulate data and findings
- Strong organizational and project management skills
- Ability to prioritize tasks, meet deadlines, and coordinate cross-functional initiatives
- Ability to assess and manage risks associated with health insurance products
- ability to apply appropriate risk mitigation strategies
- Strong written and verbal communication skills
- ability to clearly convey complex technical information to non-technical stakeholders
- Ability to identify challenges, evaluate potential solutions, and develop effective approaches to complex problems
- Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse
Desired Qualifications
- Experience with payment integrity within Marketplace or commercial lines of business
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