Are you passionate about ensuring accuracy and driving efficiency in healthcare reimbursement? At UPMC Health Plan, we're looking for a Senior Payment Accuracy Analyst to play a critical role in shaping how claims are processed and paid. This is your opportunity to make a real impact on payment integrity and compliance while collaborating with talented teams across the organization.
This position is hybrid. There is an in-office requirement of at least once per month. Additional time in the office may be required based on business needs.
What You'll Do
In this role, you'll be the go-to expert for payment accuracy and claim editing. You'll work closely with our external software vendor and internal teams to implement and maintain industry-standard clinical coding edits. Your insights will help us ensure compliance with Medicare, Medicaid, and other payor requirements while identifying opportunities for cost savings.
Here's what your day-to-day will look like:
- Collaborate across teams: Partner with Claims Operations, Medical Policy, IT, and more to align edits with clinical and financial goals.
- Lead impactful projects: Drive initiatives that monitor and adapt to changes in payment and medical policy.
- Be the subject matter expert: Advise leadership on coding and policy changes, ensuring edits work as intended and meet compliance standards.
- Stay ahead of the curve: Keep up with industry trends, regulatory updates, and evolving payment models.
- Turn data into decisions: Analyze data, spot meaningful patterns, and translate those insights into clear guidance that drives action.
What We're Looking For
- Deep knowledge of coding standards and claim editing (AMA, CMS, NCCI.
- Ability to analyze complex data, identify root causes, and recommend solutions.
- Excellent communication skills to work with leadership and cross-functional teams.
- A proactive mindset to lead projects and drive continuous improvement.
- Prior work experience in Claim Editing, Payment Integrity, or other healthcare claims operations-related fields is strongly preferred.
Nice-to-Have
- Prior experience with clinical coding and/or medical record review.
- Prior experience with policy research (CMS, PA State Medicaid, etc, interpretation, and source documentation.
- Bachelor's degree and 4 years of relevant experience OR equivalent combination of education & work within healthcare payers/claims payment processing will be considered
- Previous experience with SQL, Power BI and or Tableau highly preferred.
- Current certified coder (CCS, CCS-P or CPC, or Registered Health Information Technician (RHIA/RHIT preferred, but not required
- Ability to interpret claim edit rules and references
- Solid understanding of claims workflow and the ability to interpret professional and facility claim forms
- Ability to apply industry coding guidelines to claim processes
- Ability to perform audits of claims processes and apply root-cause
- Significant experience with Excel for data analysis and creating reports for senior management
- Familiarity with relational databases, such as Microsoft Access, SQL, etc.
- Excellent verbal & written communication skills
Licensure, Certifications, and Clearances:
UPMC is an Equal Opportunity Employer/Disability/Veteran