Note: The job is a remote job and is open to candidates in USA. Signature Performance, Inc. is dedicated to improving healthcare administrative costs for federal government agencies and providers. The Payment Analyst will ensure the accuracy and compliance of healthcare claim payments while leading audits, developing claims editing rules, and collaborating with various teams to enhance payment integrity processes.
Responsibilities
- Lead complex claim audits and investigations involving high-risk or high-value claims
- Design, develop, and maintain advanced claims editing rules and logic
- Translate complex regulatory and reimbursement policies into system specifications
- Oversee 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 integrity methodologies
- Mentor junior analysts and provide 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
- Perform 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 healthcare 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 pathways, and acceptance criteria
- Support configuration and optimization of claims editing platforms (e.g., Optum CES, TriZetto Facets)
- Analyze large datasets to identify trends, anomalies, and root causes of payment errors
- Develop SQL queries and reports to support audit findings and rule validation
- Perform 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 healthcare 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 integrity issues
- Communicate findings, policy interpretations, and recommendations to stakeholders
Skills
- Associate's or Bachelor's degree in Health Administration, Public Health, Business, or related field (or equivalent experience)
- 5+ years of experience in healthcare claims, payment integrity, auditing, or revenue cycle
- Advanced expertise in coding systems, reimbursement methodologies, and CMS regulations
- Strong experience with claims editing platforms (e.g., Optum CES)
- Advanced SQL and data analysis skills
- Demonstrated experience in rule development and system configuration
- Experience with Tricare and Veterans Administration, Medicare, Medicaid, and/or commercial 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, Excel (pivot tables, VLOOKUP, data manipulation), Experience with EDI transactions, CMS-1500, and claims workflows
- One or more of the following: CPC (Certified Professional Coder), CCS / CCS-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