Payment Integrity Analyst-PCHP (Hybrid)

Are you looking for a career that offers both purpose and the opportunity for growth? Parkland Community Health Plan (PCHP) is a proud member of the Parkland Health family. PCHP is a Medicaid Managed Care Organization servicing Texas Medicaid and CHIP in the Dallas Service Area. PCHP works to fulfill of our mission by empowering members to live healthier lives. By joining PCHP, you become part of a team focused on innovation, person-centered care, and fostering stronger communities. As we continue to expand our services, we offer opportunities for you to grow in your career while making a meaningful impact. Join us and work alongside a talented team where healthcare is more than just a job-it's a passion to serve and improve lives every day.

Primary Purpose

Parkland Community Health Plan's (PCHP's) Payment Integrity Analyst conducts analysis of claims and payment data across the health plan in support of ensuring payment integrity and cost containment. Identifies anomalous utilization patterns, investigates potential fraud, waste, or abuse, and ensures compliance with regulatory and contractual agreements. The analyst will reconcile and validate claims data, test the integrity of utilization and payment information, and support corrective action plans in coordination with internal departments and external vendors.

Minimum Specifications

Education

• Bachelor's degree in business administration, finance, healthcare, or a related field is required.

Experience

• Three (3) years of experience in payment integrity, claims analysis, or auditing within a healthcare setting.
• Experience with claims coding (DRG, ICD-10, CPT-4) required.
• Proficiency in SQL required.
• Experience with behavioral health claims is a plus.
• Experience working with TMHP claims and Medicaid regulatory requirements is preferred.

Skills or Special Abilities

• Expertise in Texas Medicaid regulations, claims processes, and reimbursement methodologies.
• Strong analytical and problem-solving skills with a focus on cost containment.
• Ability to write, troubleshoot, and optimize SQL queries for data extraction and reporting.
• Excellent communication skills for collaboration with cross-functional teams.
• Ability to interpret healthcare financial data and detect anomalies.
• Strong organizational skills with the ability to manage multiple projects and deadlines.
• High attention to detail and accuracy in data reconciliation and reporting.
• Ability to work under general supervision while proactively identifying issues and proposing solutions.
• Knowledge of Texas Medicaid, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual.

Responsibilities

Operations

• Collaborates with internal and external stakeholders to gather, analyze, and document claims and payment data.
• Conducts audits and reviews of claims and payments to identify discrepancies, overpayments, underpayments, and potential fraud.
• Prepares detailed reports of findings and recommends corrective actions or process improvements.
• Analyzes trends and emerging issues in payment accuracy and proposes strategies to mitigate risks.
• Develops, implements, and maintains tools and processes to support ongoing payment integrity monitoring.
• Interprets and understands unfamiliar data schemas to support claims analysis.
• Supports data formatting, validation, and error remediation to improve claims accuracy.
• Communicates findings, analysis, and documentation to cross-functional teams and leadership.

Regulatory

• Ensures work is carried out in compliance with applicable laws, regulatory, policies, and/or accreditation standards as well as contractual requirements.

Quality

• Identifies ways to improve work processes and enhance customer satisfaction.
• Integrate health literacy principles into all communication including Members and Providers.
• Support strategies that meet clinical, quality and network improvement goals.
• Promote the use of Health Information Technology to support and monitor the effectiveness of health and social interventions and make data-driven recommendations as needed.
• For staff in clinical roles, foster collaborative relationships with members and/or providers to promote and support evidence-based practices and care coordination.

Professional Accountability

• Promotes and supports a culturally welcoming and inclusive work environment.
• Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values.
• Adheres to organizational policies, procedures, and guidelines.
• Completes assigned training, self-appraisal, and annual health requirements timely.
• Adheres to hybrid work schedule requirements.
• Attends required meetings and town halls.
• Recognizes and communicates ethical and legal concerns through the established channels of communication.
• Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information.
• Maintains confidentiality at all times.
• Performs other work as requested that is reasonably related to the employee's position, qualifications, and competencies.

Job Accountabilities

1. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP.
2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
3. Maintains knowledge of applicable rules, regulations, policies, laws, and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.

Parkland Community Health Plan (PCHP) prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.