Job Description

What you can expect!

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

Reporting to the Manager, Payment Integrity Operations, the Senior Payment Integrity Analyst provides lead level analyst support to a team of Payment Integrity Analysts on daily operations of vendor(s) and internal programs for Payment Integrity. The incumbent provides quality assurance of junior analysts’ work and action on remediation plans to develop cost avoidance opportunities. This position leads the reporting and tracking of all vendor activity to provide daily and monthly reporting to management. The incumbent partners with leaders and functional representatives to drive health plan financial performance through evaluation and execution of operational initiatives tied to payment integrity (PI) and provider claims accuracy. The Senior Payment Integrity Analyst makes recommendations that inform decisions which contribute to health plan strategy, and acts as a trusted voice in assessing and assisting resolution of complex business challenges that impact cost-containment and regulatory compliance.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Additional Benefits

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

Competitive salary
State of the art fitness center on-site
Medical Insurance with Dental and Vision
Life, short-term, and long-term disability options
Career advancement opportunities and professional development
Wellness programs that promote a healthy work-life balance
Flexible Spending Account – Health Care/Childcare
CalPERS retirement
457(b) option with a contribution match
Paid life insurance for employees
Pet care insurance

Key Responsibilities

Audit and Investigation Lead efforts to improve claim payment accuracy and financial performance. Review pre- and post-pay claims to identify overpayments, underpayments, and billing inaccuracies.

Data Analysis & Reporting Develop and refine complex audit data mining techniques to detect irregularities, billing trends, and potential Fraud, Waste, and Abuse (FWA) and translate insights into actionable remediation strategies. Analyze large datasets using tools (SQL, Excel) to identify trends, anomalies, and root causes of payment errors. Design and maintain dashboards, trend analyses, and audit tracking tools to provide insight into payment error patterns, vendor performance, and program effectiveness.

Provider/Payer Collaboration Work with providers to resolve payment discrepancies and defend or challenge reimbursement decisions.

Complex Auditing Conduct comprehensive reviews of inpatient/outpatient claims, itemized bills, and DRGs (Diagnosis-Related Groups) to identify improper payments. Serve as a subject-matter expert for complex CMS/DHCS regulatory interpretation and operational application into PI audit strategies, system edits, and business rules.

Lead & Mentorship Provide training, coaching, and QC (quality control) support to junior analysts to ensure accurate work.

Vendor Audit Oversee vendor audit pipelines, validate findings, monitor performance metrics, generate financial impact reports, and ensure audit methodologies align with contractual and regulatory standards.

Compliance & Policy Interpret and apply federal/state regulations (CMS) and provider contract terms for audits. Ensure regulatory requirements are met for pre-pay edits, post-payment datamining, and overpayment recovery.

Strategy & Improvement Collaborate with leadership in the development of new audit concepts, test system edits, and collaborate on initiatives to reduce financial leakage.

Appeal Management Analyze and resolve provider inquiries and appeals regarding payment adjustments. Prepare comprehensive appeal defense packages, analyze overturn trends, and recommend process improvements to strengthen audit defensibility.

Perform any other duties as required to ensure Health Plan operations and department business needs are successful.

Qualifications

Education & Requirements

A minimum of five (5) years of experience in a combination of payment integrity, claims auditing, and/or medical coding required
Strong data analysis/queries experience
Experience with contract and Division of Financial Responsibility (DOFR) interpretation
Bachelor’s degree in business, health administration, or a related field from an accredited institution required
- In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position
- This experience is in addition to the minimum years listed in the Experience Requirements above
Certification in RHIA, RHIT, CCS, CPC, CIC or similar certification preferred

Key Qualifications

Strong knowledge and deep understanding of:
- Billing regulations (CMS, HIPAA), DRG, ICD-10, and CPT coding
- Medical coding (CPT, ICD-10, HCPCS) and health insurance contracts
- The full claims lifecycle, including share of cost and coordination of benefits
- Medicaid/Medi-Cal or Medicare regulatory frameworks
- Payment integrity concepts (pre-pay audit, post-pay audit types, DRG validation, coordination of benefits and comparable concepts)
- Data file layouts and system configurations to troubleshoot and coordinate remediation efforts with IT and vendors
Strong analytical skills with the ability to analyze large datasets and identify patterns
Strong proficiency in SQL, data visualization tools, and MS Excel
Strong written and verbal communication skills, including ability to synthesize complex information
Proven ability to:
- Analyze data to inform business decisions
- Work independently and apply business judgment in a highly regulated, cross-functional environment

Start your journey towards a thriving future with IEHP and apply TODAY!

Work Model Location

Telecommute (All IEHP positions approved for telecommute work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership)

Pay Range

USD $91,249.60 - USD $120,910.40 /Yr.

About IEHP

With a mission to heal and inspire the human spirit, Inland Empire Health Plan (IEHP) is one of the top 10 largest Medicaid health plans, the largest not-for-profit Medicare-Medicaid public health plan in the country, and for the fourth year in a row, certified as A Great Place To Work®. Founded in 1996, IEHP supports more than 1.5 million Riverside and San Bernardino County residents enrolled in Medicaid or IEHP DualChoice (those with both Medi-Cal and Medicare). As of 2024, IEHP also offers Covered California plans, further ensuring health care access for even more IE residents. Today, IEHP has a robust network of quality doctors throughout our two counties and nearly 4,000 team members who are fully committed to the vision: We will not rest until our communities enjoy optimal care and vibrant health. To learn more, go to iehp.org.

Comprehensive Benefits

Competitive salary and a benefits package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.

Mission: To heal and inspire the human spirit.

Vision: We will not rest until our communities enjoy optimal care and vibrant health.

Values: We do the right thing by: Placing our Members at the center of our universe; unleashing our creativity and courage to improve health and well-being; bringing focus and accountability to our work; and never wavering in our commitment to our Members, Providers, Partners, and each other.

Winning Team Culture

Certified as A Great Place To Work® four years in a row.

Industry

Healthcare & Social Services

Company Size

1,001-5,000 employees

Headquarters

Rancho Cucamonga, CA

Year Founded

1995

Website

iehp.org

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