Program Integrity Coding & Research Analyst (Health Plan Experienced)
Core
Medical Coding subject matter expert analyzing complex provider claims, resolving claim issues, and overseeing quality audit programs for Program Integrity.
Role type
Senior IC medical coding analyst
Builds
Monthly audit reports, annual audit plans, and AI auditing workflow requirements
Domain
Healthcare / Medical Coding / Program Integrity
Required skills
CPT, ICD10, HCPCS, DRG, REV coding rules, Medicaid policy analysis, reimbursement methodology (APC, DRG, OPPS), claim accuracy audits, legal discovery support, AI tool usage
Preferred skills
AI tools and processes experience
Technologies
Microsoft Office, ticketing systems
Responsibilities
Analyze complex provider claims submissions using coding rules; determine root cause of claim issues and resolve via system/payment policy analysis; oversee quality audit programs for internal analysts; research policy impacts and communicate business risks; develop annual audit plans for high-risk providers; act as SME for claim accuracy audits and disputes; lead automation requirements for AI auditing workflows; maintain internal training processes; serve as primary contact for state/market escalations; support legal activities including discovery and trial preparation; analyze functional performance for cost savings and process improvements.
Seniority
Senior, hands-on IC
