Payment Integrity Analyst

IEHP

Payment Integrity Analyst auditing claims, coding, contracts, and overpayments for Inland Empire Health Plan. Using SQL, analytics, and regulatory expertise to improve reimbursement accuracy.

Posted 8/20/2026full-timeRancho Cucamonga • California • 🇺🇸 United StatesMid-LevelSenior💰 $80,059 - $106,059 per yearWebsite

Core Competencies

Role fit

Core Competencies

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

Demonstrates expertise in healthcare claims processing, billing, and auditing, with a strong focus on data analysis and compliance with regulatory frameworks. Proficient in medical coding systems and capable of translating analytical findings into actionable operational improvements.

Highest-signal resume keywords

Healthcare Claims ProcessingData Analysis/QueriesMedical Coding (CPT, ICD-10, HCPCS)Intermediate SQLPayment Integrity Concepts

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Data MiningDRG ValidationBilling InaccuraciesPredictive AnalyticsOverpayment IdentificationAudit DocumentationRoot Cause AnalysisBusiness Rules UpdateClaims Lifecycle UnderstandingContract Interpretation

Soft Skills

Analytical SkillsProblem-SolvingOrganizational SkillsEffective CommunicationIndependent Decision-Making

Tools & Technologies

Microsoft Office SuiteSQL

Certifications & Qualifications

RHIARHITCCSCPCCIC

Industry Keywords

CMS RegulationsMedicaid/Medi-CalMedicareHEDISCAHPSNCQA AccreditationFraud, Waste, and AbuseProvider RelationsAudit-Ready Case NotesOperational Workflows

Tech Stack

Tools & technologies

SQL

About the role

Key responsibilities & impact

Independently investigate moderate-to-complex data mining leads, claim inventories, and audit findings for errors, including DRG validation and billing inaccuracies
Determine error sources and recommend remediation actions
Develop logic for data mining concepts based on overpayment identifications
Utilize AI, predictive analytics, and SQL to identify patterns of improper spend, false positives, and trends
Apply CPT, ICD-10, HCPCS, and NDC coding systems alongside provider contract terms to ensure accurate reimbursement
Research and interpret CMS, DHCS, and industry billing guidelines
Create detailed, audit-ready case notes and maintain documentation for disputes, appeals, and client inquiries
Identify root causes of claim errors and suggest improvements to business rules and operational workflows
Update business rules, system edits, configuration, and pre/post-pay controls to reduce recurring improper payment trends
Collaborate with clinical, legal, IT, SIU/FWA, provider relations, Medical Economics, providers, and clients
Deploy logic and run it against claims-paid data to produce overpayment reports
Ensure claim activities comply with CMS regulations and internal policies
Escalate potential fraud, waste, or abuse concerns to SIU/FWA teams
Assist with provider inquiries, disputes, case summaries, claim validation, and appeals
Create audit results information for the CART team for lettering and recovery
Perform other duties required to support Health Plan operations and department business needs
Support IEHP Quality Program goals, including HEDIS, CAHPS, and NCQA Accreditation

Requirements

What you’ll need

A minimum of three (3) years of experience in a combination of healthcare claims processing, billing, and/or auditing functions required
Experience with contract and Division of Financial Responsibility (DOFR) interpretation
Experience with data analysis/queries
Bachelor’s degree in healthcare, finance, 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
Certification in RHIA, RHIT, CCS, CPC, CIC or similar certification preferred
Strong understanding of medical coding (CPT, ICD-10, HCPCS) and health insurance contracts
Strong understanding of the full claims lifecycle, including share of cost and coordination of benefits
Strong understanding of Medicaid/Medi-Cal or Medicare regulatory frameworks
Strong understanding of payment integrity concepts, including pre-pay audit, post-pay audit types, DRG validation, and coordination of benefits
Intermediate SQL and Microsoft Office Suite (Excel, Access) required
Demonstrated ability to make independent decisions in claim coding and adjudication
Strong analytical, problem-solving, and trend analysis skills
Ability to translate analytical findings into operational recommendations
Solid organizational and planning capabilities
Ability to communicate effectively with internal stakeholders and external parties
Ability to independently prioritize caseloads based on impact and timelines

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
Flexible telecommute work location