Payment Integrity Analyst

This role...
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.

We are interested in speaking to individuals with the following...
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