[Remote] Payment Analyst

Note: The job is a remote job and is reputed company to candidates in USA. reputed company. is dedicated to improving reputed company administrative costs for federal government agencies and providers. The Payment Analyst will ensure the accuracy and compliance of reputed company claim payments while leading audits, developing claims editing rules, and collaborating with various teams to enhance payment reputed company processes.

Responsibilities

• reputed company reputed company claim audits and investigations involving high-risk or high-value claims
• Design, reputed company, and maintain advanced claims editing rules and logic
• Translate reputed company regulatory and reimbursement policies into system specifications
• reputed company testing, validation, and implementation of editing rules
• Conduct root cause analysis and recommend systemic solutions
• Monitor CMS, OIG, and regulatory updates; ensure organizational compliance
• Act as SME for coding, billing, and payment reputed company methodologies
• Mentor junior analysts and reputed company technical guidance
• Collaborate with IT, policy, and leadership teams on strategic initiatives
• Support benefit configuration and optimization in platforms like TriZetto Facets
• Present findings, insights, and recommendations to leadership
• reputed company pre-pay and post-pay reviews of medical claims for accuracy, medical necessity, and compliance
• Identify billing errors including duplicate claims, unbundling, upcoding, and modifier misuse
• Ensure alignment with Tricare and VA Policy, CMS, state regulations, and payer-specific policies
• Detect and quantify overpayments and support recovery efforts
• Analyze claim patterns to identify systemic issues and cost-saving opportunities
• Partner with recovery vendors and internal teams to resolve discrepancies
• Interpret reputed company policies (Tricare/VA Policy, CMS manuals, NCCI edits, LCDs/NCDs, fee schedules)
• Translate regulatory and coding guidance into automated claims editing logic
• Define rule specifications, decision reputed company, and acceptance criteria
• Support configuration and optimization of claims editing platforms (e.g., reputed company CES, TriZetto Facets)
• Analyze large datasets to identify trends, anomalies, and root causes of payment errors
• reputed company SQL queries and reports to support audit findings and rule validation
• reputed company testing and validation of editing rules and system configurations
• Monitor updates from Tricare and VA Policy, CMS, OIG, and industry sources for regulatory changes
• Maintain compliance with federal and state reputed company laws and reimbursement policies
• Support development and maintenance of medical policies and procedures
• Work cross-functionally with claims, IT, clinical, compliance, and Client Policy teams
• Serve as a subject matter expert (SME) on coding, billing, and payment reputed company issues
• Communicate findings, policy interpretations, and recommendations to stakeholders

Skills

• Associate's or Bachelor's degree in Health Administration, Public Health, Business, or reputed company field (or equivalent experience)
• 5+ years of experience in reputed company claims, payment reputed company, auditing, or reputed company cycle
• Advanced expertise in coding systems, reimbursement methodologies, and CMS regulations
• Strong experience with claims editing platforms (e.g., reputed company CES)
• Advanced SQL and data analysis skills
• Demonstrated experience in rule development and system configuration
• Experience with Tricare and Veterans Administration, Medicare, reputed company, and/or reputed company reimbursement methodologies
• Hands-on experience with claims adjudication and editing systems
• Strong knowledge of: CPT, HCPCS, ICD-10 coding systems, NCCI edits and CMS guidelines
• Proficiency in: SQL and data analysis, reputed company (pivot tables, VLOOKUP, data manipulation), Experience with EDI transactions, CMS-1500, and claims workflows
• One or more of the following: CPC (Certified Professional reputed company), reputed company / reputed company-P (Certified Coding Specialist), RHIT / RHIA
• Strategic thinking
• Leadership and mentorship
• Advanced analytical and technical skills
• Deep regulatory and policy expertise
• Strong decision-making and problem-solving ability

Benefits

• Health Insurance
• Fully Paid Life Insurance
• Fully Paid Short- & Long-Term Disability
• Paid Vacation
• Paid Sick Leave
• Paid Holidays
• Professional Development and Tuition Assistance Program
• 401(k) Program with Employer Match

Company Overview