Payment Integrity Analyst
Position Summary
The Facets Payment Integrity Analyst is responsible for supporting payment accuracy, claim cost containment, and payment integrity initiatives within a health plan environment. This role leverages expertise in the TriZetto Facets platform, claims processing, provider reimbursement, and payment integrity methodologies to identify, investigate, and resolve claims payment discrepancies. The analyst collaborates with Claims Operations, Configuration, Provider Network, Compliance, Finance, and Vendor partners to ensure accurate claim adjudication and recovery of overpayments while maintaining regulatory compliance and operational efficiency.
Essential Duties and Responsibilities
Payment Integrity & Claims Analysis
- Analyze medical, behavioral health, and ancillary claims to identify payment inaccuracies, overpayments, underpayments, and billing irregularities.
- Perform pre-payment and post-payment claim reviews to ensure adherence to benefit plans, provider contracts, reimbursement methodologies, and regulatory requirements.
- Investigate payment integrity opportunities including duplicate claims, unbundling, upcoding, incorrect coding, coordination of benefits (COB), and provider billing discrepancies.
- Research and document root causes of payment errors and recommend corrective actions.
Facets System Support
- Utilize the Facets claims processing platform to analyze claims transactions, benefit plans, provider contracts, and payment outcomes.
- Review claim adjudication logic and identify configuration issues impacting payment accuracy.
- Partner with Configuration and IT teams to validate system changes, enhancements, and payment integrity initiatives.
- Support testing and quality assurance activities related to Facets enhancements, benefit updates, and reimbursement changes.
Recovery & Cost Containment
- Identify and quantify overpayment recovery opportunities.
- Coordinate with recovery vendors and internal teams to facilitate recovery efforts and track results.
- Monitor payment integrity savings and recovery performance metrics.
- Assist in developing strategies that reduce future payment errors and improve first-pass claims accuracy.
Reporting & Analytics
- Develop and maintain reports, dashboards, and trend analyses related to claims payment performance and integrity initiatives.
- Analyze large data sets to identify payment patterns, emerging risks, and cost-saving opportunities.
- Present findings and recommendations to leadership and key stakeholders.
- Track key performance indicators (KPIs) including recoveries, savings, claim accuracy, and audit outcomes.
Compliance & Collaboration
- Ensure compliance with CMS, state, federal, and health plan regulations.
- Collaborate with Claims, Provider Relations, Utilization Management, Finance, Compliance, and Vendor partners.
- Participate in internal and external audits related to claims payment accuracy.
- Support special projects and process improvement initiatives.
Required Qualifications
- Bachelor's degree in Healthcare Administration, Business, Finance, Information Systems, or related field; equivalent experience may be considered.
- 3+ years of experience in health plan claims operations, payment integrity, claims auditing, or healthcare reimbursement.
- Hands-on experience with the TriZetto Facets platform.
- Strong knowledge of healthcare claims processing, provider reimbursement methodologies, and benefit plan structures.
- Experience analyzing medical claims data and payment outcomes.
- Proficiency with Microsoft Excel, including advanced formulas, pivot tables, and data analysis.
- Strong analytical, problem-solving, and investigative skills.
- Excellent written and verbal communication skills.
Preferred Qualifications
- Experience with Medicare, Medicaid, and Commercial health plans.
- Knowledge of ICD-10, CPT, HCPCS, DRG, and revenue codes.
- Experience with payment integrity vendors and recovery programs.
- SQL, SAS, Power BI, Tableau, or other analytics/reporting tools.
- Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or similar certification.
- Experience supporting healthcare regulatory audits and compliance initiatives.
Key Competencies
- Payment Integrity Expertise
- Facets Claims Processing Knowledge
- Data Analysis and Reporting
- Healthcare Reimbursement
- Critical Thinking
- Process Improvement
- Regulatory Compliance
- Cross-Functional Collaboration
- Attention to Detail
- Project Management
Salary Range
Now, a little about us …
At Tegria, we bring bold ideas and breakthroughs to improve care, technology, revenue, and operations in ways that move healthcare organizations from patient-centered to human-centered. We are helping healthcare put people first—both patients and those who dedicate their lives to delivering care.
And at the very core of this vital work is our incredibly talented people.
People with different backgrounds who welcome challenge and change. People who listen first, ask hard questions, and make decisions to cultivate a culture of equity and inclusion. People who chase after goals, growth, and generosity. We’re real. We’re nimble, and we believe in our mission to humanize healthcare.
Perks and benefits
Top talent deserves top rewards. We’ve carefully curated a best-in-class benefits package, meant to meet you wherever you are in your life and career.
Your health, holistically. We offer a choice of multiple health and dental plans with nationally recognized networks, as well as vision benefits, a total wellness program, and an employee assistance program for you and your family.
Your financial well-being. We offer competitive wages, retirement savings plans, company-paid disability and life insurance, pre-tax savings opportunities (HSA and/or FSA), and more.
And everything in between. Our lifestyle benefits are unrivaled, including professional development offerings, opportunities for remote work, and our favorite: a generous paid-time-off program, giving you the flexibility to plan a vacation, take time away for illness (or life’s important events), and shift your schedule to accommodate those unexpected curve balls thrown your way.
Tegria is an equal employment opportunity employer and provides equal employment opportunities (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. All qualified candidates are encouraged to apply.