Payment Integrity Business Analyst

Sagility is a tech-enabled BPM services provider, a thought partner providing a broad spectrum of transformational services, to enable our clients provide efficient and hi-quality care across the healthcare system.

Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. We optimize the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics.

Leading industry analyst firms have consistently cited our service excellence, breadth of offerings, and ability to execute. The most recent being recognized as a leader for Healthcare Payer Operations in 2022 as a part The Healthcare Payer Operations PEAK Matrix® Assessment report by Everest Group. We have 38,000+ employees in 15 cities across 5 countries – India, Philippines, USA, Jamaica, and Colombia.

About SPIS (Sagility Payment Integrity Services)

Sagility’ s approach to Payment Integrity (PI) is a collaboration between our Data Mining, Coding and Clinical teams that provides predictable operational excellence through analytics-led, technology-driven solutions. Backed by our proprietary Intelligent Content Processing (ICP) software, we deliver high quality, broad automation driven for more accurate audit findings. Through our HITRUST certified platform, Contract Central, we provide Data Mining, Clinical and Claims Repricing solutions that enhance claims payment accuracy and ensure significant savings in both pre and post-pay.

Our team is currently seeking a talented Payment Integrity Business Analyst who will focus on Audit and help the user identify overpayment opportunities or to support analysis and review of activity for reporting and process improvement purposes. This role is a strong partner with the Audit team to resolve claims issues, pricing, and fix contract issues, as needed the candidate will interact with the IT team to obtain assistance where needed.

Job Summary:

The Payment Integrity Business Analyst will play a pivotal role in analyzing and improving payment processes within a healthcare organization. This role requires an individual who is highly analytical and is comfortable working in a less defined work environment with cross-functional teams to optimize payment workflows, detect errors, and ensure compliance with internal and external regulations.

Key Area of Responsibilities:

Data Analysis & Reporting:

• Analyze and evaluate claims data to identify trends, discrepancies, and areas where claims may be inaccurately paid or healthcare rules/policies have been inaccurately applied.

• Locate provider agreements and payment rules within a clients systems and load to the Sagility proprietary platform

• Review and validate potential overpayments by verifying against independent sources of truth such as provider agreements, state or CMS rules etc.

• Fix contract-pricing issues with Audit staff.

Claims Payment Review & Reconciliation:

• Review and reconcile payment discrepancies, ensuring that claims are processed correctly according to the payer guidelines, contracts, and industry standards.

• Collaborate with Claims and Billing teams to resolve payment errors and ensure accurate payments to providers.

• Investigate overpayments, underpayments, and claim denials, working with the team to identify root causes and implement corrective actions.

Process Improvement:

• Identify and document business requirements for process improvements aimed at reducing payment discrepancies and enhancing the efficiency of the payment lifecycle.

• Collaborate with IT and operational teams to design, test, and implement process improvements, automation tools, or system upgrades.

• Recommend solutions to reduce administrative costs and improve payment accuracy.

Compliance & Regulatory Adherence:

• Ensure that all payment integrity activities comply with applicable healthcare regulations (such as HIPAA, Medicare/Medicaid guidelines, and payer contracts).

• Monitor and audit payment processes to ensure adherence to internal policies and external regulatory standards.

• Support internal and external audits related to payment integrity.

Stakeholder Collaboration:

• Serve as a liaison between business teams, IT, providers, and external stakeholders to communicate issues, solutions, and process improvements related to payment integrity.

• Conduct training sessions and workshops for internal teams on payment accuracy, reconciliation procedures, and the use of relevant tools or systems.

• Provide ongoing support for payment-related queries and assist in troubleshooting payment-related issues.

Technology Utilization & Tools:

• Leverage payment integrity systems and software tools to track and monitor claims and payment discrepancies.

• Collaborate with IT to ensure proper system functionality and data integration across platforms.

• Utilize advanced Excel functions, SQL queries, or business intelligence tools (e.g., Tableau, Power BI) to perform complex data analysis.

Education & Experience:

• Bachelor's degree

• Understanding of claims processing and the lifecycle of a claim.

• 5 plus years of experience with healthcare reporting and analytics required

• Knowledge of healthcare economics

• Experience with CMS inpatient and Outpatient claim regulations

• Experience with State Medicaid pricing.

Skills & Competencies:

• MS SQL experience- Moderate Level,

• Experience with relational and non-relational databases,

• Knowledge OF ICD10, CPT, DRG coding,

• Experience identifying and measuring business trends.

• Project Management experience researching system enhancements,

• Strong people skills to communicate with a wide range of auditor skillsets.

• Strong collaboration skills and ability to work independently and as part of a team.

• Ability to thrive in a fast paced, changing environment.

• Ability to create understanding of and obtain buy in on proposed solutions.

• Strong organizational skills with the ability to manage multiple priorities and deadlines.

Preferred Skills:

Knowledge OF ICD10, CPT, DRG coding.

Salary Range starting at $160,000.00 and up dependent on experience

Sagility Offers Competitive Benefits Including:

• Medical

• Dental

• Vision

• Life Insurance

• Short-Term and Long-Term Disability

• Flexible Spending Account

• Life Assistance Program

• 401K with employer contribution

• PTO and Sick Time

• Tuition Reimbursement

Join our team, we look forward to talking with you!

An Equal Opportunity Employer/Vet/Disability