Are you passionate about making a difference in people's lives? Do you enjoy working in a service-oriented industry? If so, this opportunity may be the right fit for you!
The Payment Integrity Analyst is responsible for reviewing non-emergency medical transportation (NEMT) claims to identify potential fraud, waste, and abuse (FWA), billing discrepancies, and payment inaccuracies. This role analyzes transportation claims and supporting documentation to determine whether claims meet contractual, regulatory, and company requirements and recommends approval, denial, adjustment, or recovery based on established payment integrity standards.
The ideal candidate is a detail-oriented and analytical professional with strong investigative skills and knowledge of payment integrity principles, claims analysis, and fraud, waste, and abuse detection. They are comfortable reviewing large volumes of claims and operational data, identifying trends and discrepancies, and making well-supported recommendations.
This role works closely with Payment Integrity leadership, the Special Investigations Unit (SIU), Claims Operations, Compliance, Provider Relations, and other internal stakeholders to help ensure accurate claim payments, protect company and client resources, and support program integrity initiatives.
Reviews submitted NEMT claims for indicators of fraud, waste, abuse, billing discrepancies, duplicate billing, overpayments, and other payment integrity concerns.
Analyzes claims, trip documentation, authorizations, provider records, contracts, and other supporting documentation to determine claim validity.
Recommends approval, denial, adjustment, or recovery of claims based on findings and established payment integrity guidelines.
Documents claim reviews, findings, and recommendations accurately and thoroughly within designated systems.
Identifies trends, patterns, or anomalies that may indicate improper billing or potential fraudulent activity and refers appropriate cases to the Special Investigations Unit (SIU).
Ensures claim determinations comply with contractual obligations, client requirements, company policies, and applicable federal and state regulations.
Collaborates with Claims Operations, SIU, Compliance, Provider Relations, and other internal departments to resolve claim issues and support payment integrity initiatives.
Assists in identifying opportunities to improve payment integrity processes, controls, and audit methodologies.
Maintains established productivity, quality, and turnaround time expectations.
Prepares reports and communicates findings to leadership as requested.
Maintains confidentiality of sensitive information and complies with HIPAA and all applicable privacy and security requirements.
Participates in ongoing training related to payment integrity, fraud prevention, and NEMT operations.
Performs other duties as assigned.
High school diploma required.
Bachelor's degree from an accredited college or university preferred.
Four (4) years of directly related experience in claims analysis, Payment Integrity, Special Investigations Unit (SIU), or Fraud, Waste, and Abuse (FWA) investigations.
Strong analytical and investigative skills with exceptional attention to detail.
Knowledge of payment integrity principles and fraud, waste, and abuse detection techniques.
Understanding of NEMT claims processing, provider billing practices, and supporting trip documentation.
Ability to analyze large volumes of claim and operational data to identify trends and payment discrepancies.
Ability to exercise sound judgment and make well-supported recommendations regarding claim approval, denial, or recovery.
Strong written and verbal communication skills.
Proficiency in Microsoft Office Suite, particularly Excel.
Ability to manage multiple priorities while meeting deadlines.
Demonstrated integrity, professionalism, and commitment to confidentiality.
Experience with non-emergency medical transportation (NEMT) claims and operations preferred.
Experience working with Medicaid managed care programs preferred.
Knowledge of NEMT provider billing practices, trip documentation requirements, and authorization processes preferred.
Experience using claims management systems and data analysis tools preferred.
Professional certification related to fraud examination, investigations, auditing, or payment integrity preferred.
Salary: $24.88-$32.00
The physical demands described are representative of those that must be met by an employee to successfully perform the essential functions of the position. Reasonableaccommodationsmay be made to enable qualified individuals with disabilities to perform the essential functions of the job.
Primarily seated work; extensive computer and telephone use; occasional standing, walking, reaching, bending, andlifting upto 10 lbs.
Modivcare’s positions are posted and open for applications for a minimum of 5 days. Positions may be posted for a maximum of 45 days dependent on the type of role, the number of roles, and the number of applications received. We encourage our prospective candidates to submit their application(s) expediently so as not to miss out on our opportunities. We frequently post new opportunities and encourage prospective candidates to check back often for new postings.
We value our team members and realize the importance of benefits for you and your family.
Modivcare offers a comprehensive benefits package to include the following:
Modivcare is an Equal Opportunity Employer.
Modivcare is a technology-enabled healthcare services company, which provides a suite of integrated supportive care solutions for public and private payors and their patients. Our value-based solutions address the social determinants of health (SDoH), enable greater access to care, reduce costs, and improve outcomes. We are a leading provider of non-emergency medical transportation (NEMT), personal care services, and monitoring.
