Senior Payment Integrity Analyst

IEHP

Senior Payment Integrity Analyst improving claims accuracy and cost containment for IEHP, a California health plan. Leading audits, analytics, vendor oversight, and payment-integrity remediation.

Posted 8/20/2026full-timeRancho Cucamonga • California • 🇺🇸 United StatesSenior💰 $91,250 - $120,910 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in payment integrity, claims auditing, and medical coding, with strong analytical skills to identify trends and anomalies in large datasets. Proficient in regulatory compliance and contract interpretation, ensuring accurate claims processing and financial performance.

Highest-signal resume keywords

Payment Integrity AnalysisClaims AuditingSQL ProficiencyRegulatory Compliance KnowledgeData Analysis

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Data AnalysisClaims AuditingMedical CodingSQLExcelData VisualizationBilling RegulationsDRG CodingCPT CodingFraud Detection

Soft Skills

Communication SkillsAnalytical ThinkingProblem SolvingCoachingCollaboration

Tools & Technologies

Data Visualization ToolsAudit Tracking ToolsDashboards

Certifications & Qualifications

RHIARHITCCSCPCCIC

Industry Keywords

CMSHIPAAMedicaidMedi-CalMedicareClaims LifecycleFinancial ResponsibilityPayment AccuracyCost ContainmentRegulatory Frameworks

Tech Stack

Tools & technologies

SQL

About the role

Key responsibilities & impact

Provide lead-level analyst support for daily operations of payment integrity vendors and internal programs
Perform quality assurance of junior analysts’ work and act on remediation plans to develop cost avoidance opportunities
Lead reporting and tracking of vendor activity, including daily and monthly reporting to management
Partner with leaders and functional representatives to improve health plan financial performance through payment integrity and provider claims accuracy initiatives
Make recommendations informing health plan strategy and help resolve complex cost-containment and regulatory-compliance challenges
Lead efforts to improve claim payment accuracy and financial performance
Review pre- and post-pay claims to identify overpayments, underpayments, and billing inaccuracies
Develop and refine audit data-mining techniques to detect irregularities, billing trends, and potential Fraud, Waste, and Abuse (FWA)
Analyze large datasets using SQL and Excel to identify trends, anomalies, and root causes of payment errors
Design and maintain dashboards, trend analyses, and audit tracking tools
Work with providers to resolve payment discrepancies and defend or challenge reimbursement decisions
Conduct comprehensive reviews of inpatient/outpatient claims, itemized bills, and DRGs to identify improper payments
Serve as subject-matter expert for CMS/DHCS regulatory interpretation and operational application in audit strategies, system edits, and business rules
Provide training, coaching, and quality-control support to junior analysts
Oversee vendor audit pipelines, validate findings, monitor performance metrics, generate financial impact reports, and ensure methodologies align with contractual and regulatory standards
Interpret and apply federal/state regulations and provider contract terms for audits
Ensure requirements are met for pre-pay edits, post-payment datamining, and overpayment recovery
Collaborate with leadership to develop audit concepts, test system edits, and reduce financial leakage
Analyze and resolve provider inquiries and appeals regarding payment adjustments
Prepare appeal defense packages, analyze overturn trends, and recommend process improvements
Perform other duties as required to support Health Plan operations and department needs

Requirements

What you’ll need

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; 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
Strong knowledge of billing regulations (CMS, HIPAA), DRG, ICD-10, and CPT coding
Knowledge of medical coding (CPT, ICD-10, HCPCS) and health insurance contracts
Knowledge of the full claims lifecycle, including share of cost and coordination of benefits
Knowledge of Medicaid/Medi-Cal or Medicare regulatory frameworks
Knowledge of payment integrity concepts
Knowledge of data file layouts and system configurations
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
Proven ability to work independently and apply business judgment in a highly regulated, cross-functional environment

Benefits

Comp & perks

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
Remote telecommute work model