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Payment Integrity Analyst
ModivcarePayment Integrity Analyst reviewing NEMT claims for Modivcare, which facilitates non-emergency transportation and home care. Detecting FWA, billing discrepancies, and payment inaccuracies while recommending claim outcomes.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in claims analysis and payment integrity, with a strong focus on fraud detection and compliance with federal and state regulations. Proficient in analyzing claims data and documentation while maintaining confidentiality and professionalism.
Highest-signal resume keywords
Claims AnalysisPayment IntegrityFraud Detection TechniquesNEMT Claims ProcessingMicrosoft Excel Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims AnalysisPayment Integrity PrinciplesFraud, Waste, and Abuse DetectionData AnalysisNEMT Claims ProcessingProvider Billing PracticesTrip Documentation AnalysisClaim RecommendationsClaims Management SystemsAudit Methodologies
Soft Skills
Analytical SkillsAttention to DetailSound JudgmentWritten CommunicationVerbal Communication
Tools & Technologies
Microsoft Office SuiteClaims Management SystemsData Analysis Tools
Certifications & Qualifications
Fraud Examination CertificationInvestigations CertificationAuditing CertificationPayment Integrity Certification
Industry Keywords
NEMTMedicaid Managed CarePayment IntegrityFraud PreventionComplianceConfidentialityContractual ObligationsClient RequirementsFederal RegulationsState Regulations
About the role
Key responsibilities & impact- Review submitted NEMT claims for fraud, waste, abuse, billing discrepancies, duplicate billing, overpayments, and other payment integrity concerns
- Analyze claims, trip documentation, authorizations, provider records, contracts, and supporting documentation to determine claim validity
- Recommend claim approval, denial, adjustment, or recovery based on findings and established guidelines
- Document claim reviews, findings, and recommendations accurately in designated systems
- Identify trends, patterns, and anomalies indicating improper billing or potential fraudulent activity
- Refer appropriate cases to the Special Investigations Unit (SIU)
- Ensure claim determinations comply with contractual obligations, client requirements, company policies, and federal and state regulations
- Collaborate with Claims Operations, SIU, Compliance, Provider Relations, and other internal departments
- Assist with improving payment integrity processes, controls, and audit methodologies
- Maintain productivity, quality, and turnaround-time expectations
- Prepare reports and communicate findings to leadership
- Maintain confidentiality and comply with HIPAA and privacy and security requirements
- Participate in ongoing payment integrity, fraud prevention, and NEMT operations training
- Perform other duties as assigned
Requirements
What you’ll need- 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, SIU, or 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
- Ability to exercise sound judgment and make well-supported claim recommendations
- Strong written and verbal communication skills
- Proficiency in Microsoft Office Suite, particularly Excel
- Ability to manage multiple priorities and meet deadlines
- Demonstrated integrity, professionalism, and commitment to confidentiality
- Experience with NEMT claims and operations preferred
- Experience 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
Benefits
Comp & perks- Medical, Dental, and Vision insurance
- Employer Paid Basic Life Insurance and AD&D
- Voluntary Life Insurance (Employee/Spouse/Child)
- Health Care and Dependent Care Flexible Spending Accounts
- Pre-Tax and Post-Tax Commuter and Parking Benefits
- 401(k) Retirement Savings Plan with Company Match
- Paid Time Off
- Paid Parental Leave
- Short-Term and Long-Term Disability
- Tuition Reimbursement
- Employee Discounts (retail, hotel, food, restaurants, car rental and much more!)