Payment Integrity Analyst

Summary

Join Rialtic as a Payment Integrity Analyst III and research, interpret, and apply CMS, CPT/AMA, and other payer policies to develop claims editing logics. You will collaborate with cross-functional teams to ensure accuracy and promote payment accuracy and transparency across various lines of business. Leverage your expertise in revenue cycle, coding, and billing to interpret policy and support edits with official documentation. Validate edits, maintain industry knowledge, and independently meet productivity goals. This role requires strong analytical skills, collaboration, and proficiency in relevant software. The position offers the opportunity to grow your technical skills in the SaaS healthcare tech space and contribute to reducing healthcare costs and improving quality of care.

Requirements

• Bachelor’s Degree preferred in Healthcare, Technology, or experience in a related field
• 8+ years of professional experience in Healthcare, familiar with medical coding terminology
• Experience working for a payer or editing vendor
• Payment accuracy experience with prepayment or post-payment knowledge
• Intermediate level proficiency in Excel (ability to manipulate data using excel functions along with pivot tables, VLOOKUP, etc)
• Solid understanding of claims workflow, including the interconnection with claim forms (CMS 1500 & UB-04)
• Experience reading and analyzing Medicare/Medicaid data and policy, which includes fee schedules, CCI, OIG Alerts, LCAs/LCDs, NCDs
• Experience reading Medicare/Medicaid policies and applying industry coding guidelines to claim processes
• Reading updated policy (e.g., CPT, Medicare, Medicaid) and updating existing payment accuracy guidelines (Maintenance)
• Collaboration Skills: Ability to communicate & collaborate with different departments such as Engineering & Product teams
• Proficient Computer skills: Ability to self-learn Google Workspace, Amazon Workspace, Jira, SmartDraw and other software with minimal guidance

Responsibilities

• Review healthcare policy (Medicaid manuals, fee schedules, CCI, OIG Alerts, LCAs/LCDs, NCDs, Medicare manuals, etc.) for coding and billing guidelines that you will interpret and use data validation to ensure the policy and specs align
• Work with the concept creation team who create billing edits that provide clients with monetary savings and promote coding accuracy, to ensure accuracy and provide feedback on their edits
• Ensure that the structural design follows the policy intent by using data analysis
• Build unit tests to verify the functionality of the edits
• Apply revenue cycle, coding, and billing expertise to interpret policy based on correct coding, billing, and auditing guidelines
• Provide in-depth research on regulations and support edits with official documents
• Validate if edits are working as intended and support decisions with validation data
• Maintain current industry knowledge of claim edit references including, but not limited to: AMA, CMS, NCCI
• Collaborate with the Content and Engineering & Data teams to develop, adjust, and validate edits
• Provide subject matter expertise on several professional claims top error areas in coding and billing across multiple specialties
• Independently meet weekly productivity and quality goals
• Be a self-starter and remain driven while independently working remotely

Preferred Qualifications

• Nationally recognized coding or billing credentials: CPC, CCS-P, RHIA, CCS, CCS-P, CPB
• SQL query-building and lookup skills for claims data analysis and data mining for editing opportunities
• Claims editing experience
• Project Management experience
• Experience with mapping CMS 1500, EDI and FHIR

Benefits

• Freedom to work from wherever you work best and a home office stipend to make it happen
• Meaningful equity and 401 (k) matching
• Unlimited PTO, comprehensive health plans, and wellness reimbursements
• Comprehensive health plans with generous contributions to premiums
• Mental and physical wellness support through TalkSpace, Teladoc and One Medical subscriptions