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Collective Health · 17 hours ago

Payment Integrity Analyst

Plano, TX

Full-time

Hybrid

Entry, Mid Level

$27.20/hr - $34/hr

2+ years exp

Collective Health is transforming how employers and their people engage with their health benefits. The Payment Integrity Analyst role is focused on ensuring accurate and compliant claim payments, supporting the Payment Integrity team with expertise in medical coding, reimbursement rules, and data analysis to resolve payment inaccuracies.

Health CareHealth InsuranceInsurTech

Responsibilities

Serve as an operational liaison with external Payment Integrity vendors. Support the Coordination of implementation, testing, and ongoing maintenance of vendor-developed edits and reviews within the overall payment integrity stack

Assist in the research and support the interpretation of federal/state regulations (e.g. CMS), commercial payer policies, and develop expertise in industry-standard coding rules (CPT, ICD-10, HCPCS, NCCI, MUE)

Document clear, actionable business requirements and system logic (edits, rules) based on translations provided by senior analysts and managers

Utilize analytical tools to identify and document aberrant billing patterns and potential payment error opportunities, and support senior analysts in performing root cause analysis on identified issues

Support the execution of detailed pre- and post-payment audits, accurately calculate overpayment and underpayment amounts, and prepare comprehensive documentation to support claim recovery efforts and issue resolution

Collaborate with key internal stakeholders, including Product, Engineering, Claims Operations, and others, to ensure new edits are accurately implemented, tested, and communicated

Act as a point of escalation for complex payment disputes and claim inquiries, providing definitive analysis and support for the Payment Integrity team

Support continuous improvement efforts within the Payment Integrity workflow, focusing on streamlining processes, increasing automation, and enhancing overall claim accuracy

Qualification

Medical coding certificationSQLHealthcare reimbursement methodologiesData analysisVendor managementProcess improvementProject managementCommunication skillsCross-functional collaboration

Required

2+ years of relevant experience in healthcare claims auditing, payment integrity, or complex claims processing/adjudication, ideally within a payer or TPA setting

Medical coding certification is Preferred (e.g., CPC, COC, or CIC from AAPC, or CCS from AHIMA), or the candidate is Required to obtain it within the first year of employment if they possess comparable experience

Experience working directly with external Payment Integrity or FWA vendors to develop, deploy, and manage claim editing capabilities or similar experience

Demonstrated proficiency in leveraging data to solve business problems, with hands-on experience in SQL or other database skills (e.g., Looker) for retrieving and analyzing data against large claims datasets

Strong, practical knowledge of healthcare reimbursement methodologies (e.g., RBRVS, DRG, fee schedules) and the end-to-end claims lifecycle

Experience handling cross-functional projects at a small to mid-sized organization

Ability to handle multiple tasks/projects under tight deadlines

Strong internal & external communication

Working in a highly matrixed environment