Build your Career. Make a Difference. Presbyterian is hiring a skilled Medical Economics Analyst-Payment Integrity to join our team.
Type of Opportunity: Full time
Job Exempt: Yes
Job is based: Remote Workers New Mexico
Work Shift: Weekday Schedule Monday-Friday (United States of America)
Responsibilities
Some key responsibilities include:
Partner closely with Payment Integrity, Operations, and vendor partners (e.g., Cotiviti, Optum) to support pre-pay and post-pay initiatives
Analyze claims data to identify patterns of overpayment, billing anomalies, and coding discrepancies
Support development and refinement of rules, algorithms, and audit strategies to improve payment accuracy
Translate operational PI activities into measurable financial outcomes tied to TCOC
Validate identified savings opportunities through detailed claims-level analysis and audit review
Develop and maintain methodologies to quantify gross and net savings (pre-pay edits, post-pay recoveries, avoidance)
Perform before/after and control group analyses to ensure credibility of savings estimates
Partner with finance to align validated savings with general ledger and financial reporting
Extract, transform, and analyze large-scale healthcare datasets using SQL, SAS, or similar tools
Work within enterprise data warehouse environments to build repeatable datasets and analytic pipelines
Develop dashboards and reporting tools to monitor payment integrity performance and trends
Support integration of external/vendor outputs into internal analytics frameworks
Produce clear, concise reporting on payment integrity performance, savings, and emerging opportunities
Develop executive-ready summaries highlighting key drivers, risks, and recommended actions
Support ongoing monitoring of initiative performance and identification of new opportunities
Generate pre-payment edit contribution invoices for Self-Funded accounts
Requirements
Bachelor's degree in Actuarial Science, Economics, Finance, Data Analytics, Healthcare Administration, or related field (or equivalent experience)
2-5+ years of experience in healthcare analytics, medical economics, or payment integrity
Strong technical skills in SQL and/or SAS (required); experience querying large relational databases
Experience working with claims data and reimbursement methodologies (fee schedules, IPPS, OPPS)
Demonstrated ability to perform financial and statistical analysis on large datasets
Strong problem-solving skills with attention to detail and data accuracy
All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.
Wellness
Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.
About Presbyterian Healthcare Services
Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses
Benefits
Health insuranceDental insuranceVision insuranceRemote work options
Additional Information
Location Address:
Remote Office
Santa Fe, NM 87501
Compensation Pay Range:
Minimum Offer $83,366.40
Maximum Offer $127,275.20
Now Hiring: Medical Economics Analyst-Payment Integrity
Phsorg · Remote