Payment Integrity Analyst

Come Grow With Us
At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges.

Working at Gold Coast Health Plan means working alongside a team of committed individuals who are reshaping the organization and redefining how the needs of the whole person - health, health care, and social services and supports - are met. We are seeking collaborators, innovators, and those who are driven to be their very best.

If you are looking for a career of purpose and are passionate about having an impact on society's health care challenges, then Gold Coast Health Plan is where you should be. Here, you will be challenged and rewarded in equal measure.

About this role:

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

Job Function & Responsibilities

* Payment Integrity Operations
o Perform prepay and postpay claim reviews to identify incorrect payments, coding errors, billing anomalies, and potential fraud, waste, or abuse.
o Validate overpayments and ensure recovery activities comply with state, federal, and contractual requirements.
o Conduct retrospective claim analysis to identify trends, systemic issues, and opportunities for process improvement.

o Support the development and maintenance of claim edits, payment rules, and audit logic.
o Review highdollar claims, complex claims, and claims flagged by PI algorithms or vendor partners.
* Data Analysis & Reporting
o Analyze large claim data sets to identify patterns, anomalies, and root causes of payment inaccuracies.
o Develop and maintain dashboards, reports, and performance metrics related to PI activities, recoveries, and risk areas.
o Prepare summaries of findings, financial impact assessments, and recommendations for corrective action.
o Present PI results, trends, and risks to internal stakeholders.
* Compliance, Audit & Documentation
o Ensure PI activities comply with DHCS, CMS, DMHC, MediCal, Medicare Advantage, and GCHP policies.
o Support internal and external audits, including DHCS readiness reviews, CMS audits, and financial audits.
o Maintain strong documentation, audit trails, and internal controls for all PI activities.
o Assist in developing corrective action plans (CAPs) and monitoring their implementation.
* Vendor & CrossFunctional Collaboration
o Collaborate with PI vendors to validate findings, review methodologies, and ensure accuracy of savings calculations.
o Monitor vendor performance, escalate issues, and support contract compliance activities.
o Partner with Claims Operations, Configuration, Finance, Compliance, Provider Network, and IT to resolve rootcause issues and improve payment accuracy.
o Support provider education and remediation efforts related to PI findings.
* Continuous Improvement
o Identify systemic payment risks and recommend process, system, or policy improvements.
o Support initiatives to enhance autoadjudication accuracy and strengthen claims editing controls.
o Contribute to the development of PI strategies, workflows, and best practices.
o Drive datadriven decisionmaking and operational improvement.

MINIMUM QUALIFICATIONS

Education & Experience:
* Bachelor's Degree (four-year college or technical school): Preferred
* Minimum 3-6 years of experience in one or more of the following areas:
o Payment Integrity or Program Integrity
o Medical cost containment
o Fraud, Waste, and Abuse (FWA)
o Claims auditing or accuracy review
o Healthcare analytics or data mining
* Experience with Medicaid/MediCal and Medicare managed care programs.
* Experience with prepay or postpay review, recovery operations, or claim logic development.
* Experience with COB/TPL claims in a managed care environment.
* Experience collaborating with or supporting PI vendors preferred.

Equivalent In lieu of degree:
* 6-8 years of progressively responsible experience in claims processing, auditing, or payment integrity roles within a MediCal or Medicaid managed care plan.

KNOWLEDGE, SKILLS & ABILITIES

Preferred Qualifications:
* Working knowledge of:
o MediCal and Medicare managed care regulations.
o Medical billing and coding (CPT, HCPCS, ICD9/10).
o COB/TPL regulations and payment methodologies.
o Claims processing systems, benefit configuration, and reimbursement logic.
o Principles of claims administration, audit, and customer service in a managed care environment.
* Ability to:
o Analyze complex data sets and identify trends, anomalies, and root causes.
o Interpret provider contracts, payment methodologies, and benefit structures.
o Conduct detailed claim reviews and rootcause analysis.
o Communicate effectively with internal teams, leadership, providers, and vendors.
o Manage competing priorities and meet regulatory turnaround times.
o Work collaboratively across departments and with external partners.
o Prepare clear, concise reports and presentations.
* Additional experience or related background in:
o Managed care operations
o Medi Cal and Medicare programs
o Leadership or supervisory roles
o Healthcare analytics, audit, or compliance functions

Technology & Software Skills: Advanced computer skills in MS Office products. Experience with claims platforms, audit tools, or data analytics software preferred.

Certifications & Licenses: Possession of, or ability to obtain, a valid appropriate California driver's license. Maintain a satisfactory driving record

Competency Statements
* Management Skills - Ability to organize and direct oneself and effectively supervise others.
* Business Acumen - Ability to grasp and understand business concepts and issues.
* Decision Making - Ability to make critical decisions while following company procedures.
* Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.
* Interpersonal - Ability to get along well with a variety of personalities and individuals.
* Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.
* Time Management - Ability to utilize the available time to organize and complete work within given deadlines.
* Consensus Building - Ability to bring about group solidarity to achieve a goal.
* Relationship Building - Ability to effectively build relationships with customers and co-workers.
* Presentation Skills - Ability to effectively present information publicly.
* Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.
* Judgment - The ability to formulate a sound decision using the available information.
* Communication, Oral - Ability to communicate effectively with others using the spoken word.
* Communication, Written - Ability to communicate in writing clearly and concisely.
* Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.

PHYSICAL DEMANDS

O (Occasionally) Position requires this activity up to 33% of the time (0 - 2.5+ hrs/day)
F (Frequently) Position requires this activity from 33% - 66% of the time (2.5 - 5.5+ hrs/day)
C (Constantly) Position requires this activity more than 66% of the time (5.5+ hrs/day)

Stand O
Walk F
Sit C
Manually Manipulate C
Reach Outward O
Grasp F
Lift 10 -20lbs O
Carry 10-20lbs O

The estimated pay range for the position is:

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.