Payment Integrity Analyst
Core
Investigate potential payment inaccuracies in Medicare Advantage claims, evaluate claims populations via SQL analysis, and determine whether evidence supports payment issues or correctly adjudicated outcomes.
Role type
Payment Integrity Analyst (Medicare Advantage claims)
Builds
Validated findings and actionable recommendations for payment corrections and sustainable controls
Domain
Healthcare insurance / Medicare Advantage claims adjudication
Required skills
Medicare Advantage claims adjudication knowledge, SQL proficiency, claims data analysis, Excel skills, AI tool usage, investigative judgment, documentation
Preferred skills
Overpayment investigation experience, claims payment rule testing, recurring audit development, coding/reimbursement credentials (via careerplan.io/jobs/8240259-payment-integrity-analyst-at-cloverhealth)
Technologies
SQL, Excel, AI tools
Responsibilities
Investigate payment inaccuracies using Medicare Advantage knowledge; Review claims populations identified through SQL analysis; Research CMS/NCCI guidance and provider contract terms; Analyze claim details, payment components, and adjustments; Independently run and adapt SQL queries; Document validation steps and findings for reproducibility; Prepare findings for Compliance/Legal review
Seniority
Mid-level, hands-on IC
