Business Analyst, Principal - Payment Integrity

Your Role

The Promise Payment Integrity team leads the research and identification of financial integrity opportunities for Medi-Cal, not limited to the recoupment of provider overpayments, reinforce compliant claims payment processes, and ensure accurate revenue oversight and reconciliation. The Principal Business Analyst will report to the Director of Medi-Cal Performance Optimization. In this role you will blend deep claims data expertise with Medicaid/Medi-Cal policy know-how to deliver near-term recoveries and long-term solutions.

Your Knowledge and Experience

• Requires mastery level knowledge of job area typically obtained through advanced education combined with experience. May have deep knowledge of project management
• Requires a bachelors degree or equivalent experience
• Requires at least 10 years of prior relevant experience
• Requires SQL expertise; strong Excel; experience with a viz tool (Power BI/Tableau) preferred
• Requires hands-on experience with claims systems (preferably Facets) - benefit, pricing, provider/network, and code-edit constructs; able to partner on config and UAT
• Medical Coding knowledge: working mastery of ICD-10-CM/PCS, CPT/HCPCS, DRG, modifiers, NCCI, POS, revenue codes. Certifications (CPC, COC, CPMA) is preferred
• Medicaid/Medi-Cal payment policy familiarity (coordination of benefits, retro eligibility, rate/benefit nuances, prior auth, state policy bulletins) is preferred
• Prior experience in a California plan with Medi-Cal (DHCS) lines of business, exposure to vendor PI programs (post-pay, pre-pay, DRG validation, coding audits) and FWA/SIU collaboration is preferred