Payment Integrity Analyst

Job Description

Location: Remote (US-based)

We are seeking a Payment Integrity Analyst to identify and document overpayment recovery opportunities across payer claims for a health plan. This position is a full-time, direct hire opportunity available on a fully remote basis within the US.

This role suits an analyst who is equally comfortable in a SQL editor and a CMS policy memo and who takes genuine satisfaction in finding the specific claims configuration behind a large recovery opportunity. You will work independently as an individual contributor from a remote home-based office, building and refining recovery concepts, stress-testing your own logic against payer adjudication behavior, and writing findings that a medical director will accept on the merits. A background in payer SIU, claims audit, or health plan analytics is ideal, and remote flexibility plus direct exposure to a broad cross-section of payer claims makes this a strong platform for analysts who want to grow their payment integrity expertise quickly.

Responsibilities:

• Query claims data warehouses to identify billing patterns violating payer medical policy and CMS coding conventions.
• Identify overpayment patterns: unbundling, upcoding, modifier misuse, place-of-service manipulation, and duplicates.
• Apply CPT, HCPCS, ICD-10, and DRG methodology to validate coding logic and confirm payable errors.
• Cite CMS policies, LCDs, CCI edits, and payer guidelines supporting recovery concepts.
• Quantify gross and net recovery per finding, adjusting for denial rates and appeal risk.
• Produce structured documentation with rationale, citations, and recovery calculations.
• Escalate complex determinations to clinical review for medical necessity and diagnosis-linkage validation.
• Track findings through QA, incorporate feedback, and maintain version-controlled documentation for appeals defense.
• Support appeals with source data pulls, policy references, and rebuttals to provider objections.

Qualifications:

• Demonstrate 3+ years payment integrity, claims audit, special investigations experience developing recovery concepts
• Master complex SQL: joins, window functions, aggregations, subqueries across Snowflake, Teradata, SQL Server, Databricks
• Master CPT, HCPCS Level II, ICD-10-CM/PCS, CCI edits, modifier rules, DRG grouper methodology independently
• Apply CMS National/Local Coverage Determinations, NCCI manuals, payer medical policies supporting payment integrity concepts
• Build Excel workbooks using pivot tables, VLOOKUP/XLOOKUP, INDEX-MATCH, conditional logic, data validation for recovery
• Produce precise, policy-grounded narratives at technical clarity satisfying medical directors and client compliance teams

Schedule:

Fully remote within the US. Standard business hours, Monday through Friday.

Salary Range: The salary range for this position is approximately $65,000 – $92,000 annually ($31.25 – $44.23 per hour), based on experience and qualifications.

Interview Process:

• Selected candidates will participate in a multi-step interview process, including an initial screening with TalentLNX followed by interviews with department leadership.

Equal Opportunity Employer: TalentLNX is committed to equal employment opportunity and a diverse, inclusive workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.