Payment Integrity Analyst II

The Payment Integrity Analyst II plays a critical role in analyzing and interpreting healthcare data to provide actionable insights for improving patient outcomes, optimizing clinical workflows, and supporting healthcare decision-making.  This position ensures accurate claims processing, policy interpretation, and regulatory alignment to prevent overpayments and cost-effective healthcare payments.   What you’ll drive :

• You’ll identify, investigate and report on wasteful and inaccurate spend in healthcare claims   You’ll work with industry leading AI, predictive analytics, and automation platforms to uncover patterns and drive smarter decisions.   You’ll foster a culture of learning, refinement, and ethical excellence to create high quality, evidence backed referrals that reduce health insurance costs.  What you’ll do :   Identify and investigate healthcare billing activities leading to improper payments.

This work involves reviewing medical professionals, facilities, insured members, or the broker community in coordination with the customer’s carrier or third-party administrator  Review claims data and conduct analysis to look for patterns of potential FWA and other improper payments  Utilizing information from claims data analysis, plan members, and other sources to conduct confidential claims data reviews, relevant investigative activities, document actionable findings and report any suspect billing that could result in an overpayment through designated channels  Conduct data analysis to review claim and case history  Reviews claims history, medical reviews, provider files, etc. and utilizes data analysis techniques to detect irregularities, billing trends, and financial relationships using state boards, licensing sites, Secretary of State sites, etc.  Identify and resolve issues related to data discrepancies, missing data, or inconsistencies within clinical datasets  What you bring :