Payment Integrity Concept Development Analyst

Required credential: Active RN license or Certified Coder (CPC/CCS/CIC/COC).

As part of the Complex Payment Solutions Team, the Concept Development Analyst applies subject matter expertise across government and commercial healthcare claim types to lead the development, maintenance, testing, and optimization of payment integrity audit concepts. This role works closely with cross-functional teams — including operations, clinical, client services, and technology — to ensure audit concepts are accurately built, validated, and maintained in alignment with coding standards, medical necessity criteria, regulatory requirements, and client-specific payer policies.

This role requires deep expertise in medical coding systems and payment methodologies, strong analytical and communication skills, and a proven ability to manage complex workflows independently. The ideal candidate brings authoritative knowledge of healthcare billing across claim types, a track record of leading audit concept development, and the ability to mentor and oversee a team of subject matter experts.

 

 

Policy Development and Maintenance

• Review and update existing audit concepts on required periodic cycles or in response to client or regulatory changes, including research, data/claim analysis, and updates to rule documents and code lists.
• Conduct research and analysis to identify the impact of regulatory, coding, or payer policy changes on existing concepts and document findings accordingly.
• Interpret and apply client-specific payer policy in audit concept reviews and updates.
• Ensure audit concepts are appropriately formulated across offering types (Data Mining vs. Complex Audit) and program lines (CMS, Medicaid, Commercial).

Policy Testing and Validation

• Perform QA reviews of audit concepts, ensuring compliance with regulatory, coding, and citation changes, and that updates are applied timely.
• Identify discrepancies in concept performance and drive resolution with clinical, coding, and operations teams.
• Ensure audit concepts are validated against current coding guidelines, payment methodologies, and payer policy prior to deployment.

Operational and Workflow Support

• Manage, track, and progress multiple tasks across concurrent audit concept workflows with a high degree of accuracy and quality, delivering results on time.
• Ensure consistent and correct application of policies across auditing platforms and client programs by the audit teams.

Training and Documentation

• Contribute to the creation of training materials, job aids, and reference tools for both new and existing audit concepts.
• Maintain organized, accessible documentation of audit policies and concept updates.

Cross-Functional Collaboration and Client Support

• Respond to client inquiries and provide subject matter support to client services for presentations and escalations.
• Partner with operations, clinical teams, technology, and internal stakeholders to support policy execution and drive concept quality.
• Provide expert feedback to improve policy usability, accuracy, and effectiveness across the organization.

Performance Monitoring and Analytics

• Monitor concept performance and provide statistical analysis to drive scoring and selection for new and existing audit concepts.
• Identify trends in concept performance data and make recommendations to optimize audit yield and accuracy.
• Stay informed of payment integrity policy developments, coding updates, and industry trends.

Process Improvement

• Identify opportunities to improve audit concept workflows, documentation processes, and policy management practices.
• Support ongoing enhancements to concept tracking, QA processes, and cross-functional coordination.

Other Duties

• Perform additional responsibilities and ad hoc projects as assigned to meet business needs.

 

 

Education and Experience

• Bachelor's degree in health administration, business, nursing, or a related field, or equivalent experience.
• Minimum 5+ years of progressive experience in healthcare claim type subject matter specialty, including direct experience in payment integrity and claims auditing.
• Equivalent experience of 3+ years in claims auditing and recovery auditing.
• Registered Nurse or Certified Coder holding a nationally recognized credential (RHIA, RHIT, AHIMA, AAPC, or equivalent) required.

 

 

Knowledge, Skills, and Expertise

• Demonstrated depth and breadth of knowledge across payment integrity elements, including: ICD-10-CM, ICD-10-PCS, CPT, HCPCS, and HIPPS coding systems and MS-DRG, APR-DRG, APC, APG, PDPM, and PDGM payment methodologies.
• Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems.
• Superior knowledge of healthcare coding, billing, reimbursement, and claim adjudication standards and procedures.
• Broad knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology.
• Expert knowledge of clinical criteria documentation requirements and audit concept development across claim types.
• Strong experience in data utilization and statistical analysis, including driving scoring and selection for audit concepts.
• Progressive healthcare data analysis experience, including gathering and documenting requirements for projects of diverse scope and complexity.
• Experience developing clinical content, policy documentation, and training resources.
• Proven ability to communicate effectively with all levels of the organization, with diverse teams, and with external clients.
• Exceptional written and verbal communication skills with strong attention to detail.
• Excellent critical thinking and analytical skills.
• Demonstrated ability to manage multiple concurrent workflows independently and in a remote environment, delivering results on time.

Computer Equipment and Software

• Proficient in Windows office systems, including the full Microsoft Suite (Excel, Word, Outlook, PowerPoint, SharePoint, and Teams).
• Advanced skills in Microsoft Office, particularly Excel and PowerPoint.
• Familiarity with multiple encoder/grouper applications.
• Experience working with various software platforms and collaborating with development teams.
• Proven success in a remote working environment.