Senior Payment Integrity Analyst

About this role: This is a data-driven, carrier-facing operations role. It combines hands-on claims analysis and overpayment identification with direct engagement of carrier analyst teams. It is designed to complement our clinical review strength — we are specifically looking for someone whose edge is data mining and pattern detection rather than clinical adjudication.

POSITION SUMMARY

As a Senior Payment Integrity Analyst on 4C Digital Health’s payment integrity team, you own the operational relationship with an assigned carrier account and are accountable for identifying overpayments, defending our findings, and converting them into recovered dollars for our clients.

You will review paid claims and carrier responses to determine whether claim determinations and their supporting documentation hold up under scrutiny — and where they do not, build and present well-supported rebuttals. You will run recurring working sessions with carrier analyst teams, drive findings to resolution, and continuously mine claims data for new overpayment opportunities. This is a hands-on operations and analysis role: the person who succeeds here is equal parts data detective and credible, organized negotiator.

WHAT YOU WILL OWN

• Serve as the operational lead and primary point of contact for an assigned carrier account — managing the day-to-day relationship, cadence, and follow-through.
• Review paid claims to identify potential overpayments, billing and coding discrepancies, and payment errors.
• Evaluate carrier responses and supporting documentation to determine whether original determinations are adequately substantiated; prepare and present clear, evidence-based rebuttals where they are not.
• Lead recurring working sessions with carrier analyst teams to review findings, resolve disputes, and move items to closure.
• Mine claims and payment data to surface new overpayment opportunities and expand the recovery pipeline.
• Track findings, rebuttals, and recoveries through resolution; report dollars identified and dollars recovered to leadership.
• Partner with clinical and coding reviewers so data-identified and clinically-identified findings reinforce one another rather than overlap.
• Document repeatable approaches and maintain account runbooks so coverage is never single-threaded.
• Surface recurring patterns — error types, documentation gaps, carrier behaviors — as opportunities to grow recoveries.

BACKGROUND WE ARE LOOKING FOR

Required:

• 7 years in payment integrity, claims audit, overpayment recovery, or healthcare claims operations
• Demonstrated experience identifying overpayments and payment errors in medical claims data
• Strong data-mining and analytical skills — comfortable working large claims datasets in Excel (pivot tables, lookups, large-file handling) and spotting patterns others miss
• Experience preparing and defending audit findings, disputes, appeals, or rebuttals with carriers, payers, or providers
• Confident, organized communicator able to lead working sessions and hold a position with carrier analyst teams using evidence
• Ability to manage findings to resolution and report on dollars identified and recovered

Strongly Preferred:

• Background at a payment integrity vendor or on a carrier / health plan payment integrity or SIU team
• Familiarity with self-funded employer health plan data — claims, eligibility, and financial / invoicing files
• Exposure to stop-loss, shared savings, DRG or coding review, or invoice reconciliation
• A coding or clinical credential (CPC, RN, or similar) is a plus — but this role is weighted toward data and carrier operations, not clinical review

A Plus (Not Required):

• Direct experience with Aetna, Anthem, Cigna, or UHC — including familiarity with their claims file formats, adjudication conventions, and analyst processes

Not Required:

• SQL, Python, or any programming language
• ETL development or software engineering background

WHAT SUCCESS LOOKS LIKE

• Overpayments identified and recovered dollars grow quarter over quarter on your account
• Rebuttals are well-supported, land credibly with carrier teams, and convert to recoveries
• Working sessions run on a predictable cadence and items move to closure rather than stalling
• Findings are documented and repeatable, so the account stays resilient and never single-threaded