Payment Integrity Analyst

Career Opportunities: Payment Integrity Analyst (17870) Requisition ID 17870 - Posted 08/30/2021 - CareOregon - Full Time - Permanent - Portland

To protect the health and well-being of our members, employees and community, CareOregon requires all employees to be fully vaccinated against COVID-19 or have an approved medical or religious exception as a qualification of employment.

Candidates who receive an offer of employment by CareOregon, must provide proof of COVID-19 vaccination or submit a medical or religious exception request, which will be evaluated in accordance with CareOregon's standard accommodation process.

Position Title: Payment Integrity Analyst

Department: Payment Integrity

Title of Manager: Payment Integrity Manager

Supervises: Non-supervisory position

Exemption Status: Exempt

Requisition: 17870

Job Summary

The Payment Integrity Analyst is responsible for executing claims investigation and recovery strategies. This includes analyzing claims data to identify cost containment opportunities across many different claims areas to ensure proper claims payments, as well as conducting in-depth simple to complex claims audits. The Payment Integrity Analyst also works to review and analyze new audit concepts and make recommendations for recoveries and partners with our vendors on additional recovery audits and investigations. The position coordinates with internal business partners in other areas such as Clinical, Contracting, Configuration, Finance, Claims and Provider Relations to ensure efforts are in sync. The role is integral in ensuring claims payment integrity as it supports all recovery efforts for claims processing.

Essential Responsibilities
  • Implement new Payment Integrity initiatives as directed by the Payment Integrity Manager and/or Director.
  • Partner with others on the Payment Integrity or Claims teams to ensure collaboration, communication and knowledge sharing to maximize team efforts and efficiency.
  • Review published Centers for Medicare and Medicaid Services (CMS)/Recovery Audit Contractor (RAC) topics for viability of Care Oregon's paid claims.
  • Review vendor overpayment suggestions for accuracy, adherence to scope, claim recovery activities, new concepts submission and claim sample approval.
  • Interact with claims payment vendor and internal departments to discuss system corrections and recommendations regarding claims overpayments.
  • Identify and document root causes of overpayments along with remediation recommendations.
  • Research and audit simple to complex claims payments including researching tools provided by the Oregon Health Authority (OHA), Medicare billing guidelines, CareOregon's claims processing policies and procedures and other resources to identify claims overpayments.
  • Enter and update recovery information in claims systems, call tracks and other payment integrity tools.
  • Prepare and create accurate and timely provider overpayment notification letters and include them with reconciliation back up documentation.
  • Consistently meet work/performance standards that include payment integrity goals, productivity, quality metrics and monthly savings goals.
  • Communicate effectively and in a professional manner with internal and external customers regarding all aspects of recovery, claims payment, provider remittances and general recovery processes.
  • Make and take calls from providers related to overpayment requests/activities.
  • Research and resolve payment disputes and provide timely follow-up.
  • Maintain a working knowledge of regulations relevant to payment recovery and claims processing.
  • Promptly escalate complex issues encountered to the Payment Integrity Manager.
  • Perform necessary claims adjustments identified in audits when/if needed.
  • Support User Acceptance Testing (UAT) for large-scale testing projects when/if needed.

Organizational Responsibilities

  • Perform work in alignment with the organization's mission, vision, and values.
  • Support the organization's commitment to equity, diversity, and inclusion by fostering a culture of open mindedness, cultural awareness, compassion, and respect for all individuals.
  • Strive to meet annual business goals in support the organization's strategic goals.
  • Adhere to the organization's policies, procedures, and other relevant compliance needs.
  • Perform other duties as needed.

Knowledge, Skills and Abilities Required

  • Solid understanding of complex claims processing and payment integrity/payment policy initiatives including manual pricing, coordination of benefits (COB), adjustments etc.
  • Working knowledge of claims coding requirements and payment methodologies (e.g. Prospective Payment System (PPS), Medicare Fee Schedules, etc.)
  • Ability to learn state and federal claims and payment integrity regulations
  • Knowledge of medical terminology
  • Knowledge and skill in using claims management systems, editing software and medical coding
  • Ability to use computer programs commonly used for health plan operations
  • Statistical, analytical and problem-solving skills
  • Strong organization skills
  • Strong detail-orientation skills
  • Adept at prioritizing work
  • Ability to work well under pressure in a complex and rapidly changing environment
  • Good spoken and written communication skills
  • Ability to present complex information to groups as needed
  • Excellent interpersonal skills
  • Ability to work independently
  • Ability to work effectively and professionally with diverse individuals and groups related to the provision of services
  • Ability to present a positive and professional image as a leader and representative of CareOregon
  • Advanced skill in Excel helpful

Physical Skills and Abilities

Lifting/Carrying up to 10 Pounds

Pushing/Pulling up to 0 Pounds

Pinching/Retrieving Small Objects



Climbing Stairs

Repetitive Finger/Wrist/Elbow/

Shoulder/Neck Movement

0 hours/day

0 hours/day

0 hours/day

0 hours/day

0 hours/day

0 hours/day

More than 6 hours/day








Speaking Clearly

0 hours/day

0 hours/day

0 hours/day

0 hours/day

More than 6 hours/day

More than 6 hours/day

3-6 hours/day

3-6 hours/day

Cognitive and Other Skills and Abilities

Ability to focus on and comprehend information, learn new skills and abilities, assess a situation and seek or determine appropriate resolution, accept managerial direction and feedback, and tolerate and manage stress.

Education and/or Experience


  • Minimum 3 years' experience in roles using Medicare and/or Medicaid claims management systems
  • Minimum 1 year' experience performing advanced claims adjustments


  • Experience performing statistical claims analysis in a managed care or health care setting
  • Clinical coding certification(s), such as Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Medical Coder (CMC), Certified Coding Associate (CCA), etc.
  • Experience with payment integrity programs and/or vendors

Working Conditions

  • Environment: This position's primary responsibilities typically take place in the following environment(s) (check all that apply on a regular basis):

Inside/office Clinics/health facilities Member homes


  • Travel: This position may include occasional required or optional travel outside of the workplace, in which the employee's personal vehicle, local transit, or other means of transportation may be used.
  • Equipment: General office equipment
  • Hazards: n/a

Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment

Veterans are strongly encouraged to apply.

Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

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Management Analysts


3 to 20+ years

Job type

Full time

Salary Range
$68,000.00 - 94,000.00
per Year
Salary range estimated by
Happy Valley, OR 97086, US
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