[Remote] Payment Integrity Operations Analyst - Remote AZ

Note: The job is a remote job and is open to candidates in USA. Blue Cross Blue Shield of Arizona is dedicated to inspiring health and providing diverse health insurance products and services. The Payment Integrity Operations Analyst is responsible for ensuring payment accuracy and operational effectiveness throughout the healthcare claims lifecycle, collaborating with various teams to identify and resolve claims processing issues.ResponsibilitiesDemonstrates solid working knowledge of claims processing and payment integrity conceptsIndependently analyzes claims issues and supports audits, rework, and reportingRequires limited guidance for routine to moderately complex workAnalyze claims processing workflows to identify payment risks, rework drivers, and systemic defects across all lines of businessSupport or lead claims rework and adjustment activities, ensuring accurate resolution and timely completionCommunicate complex claims and payment integrity topics clearly to both technical and non-technical stakeholdersApplies advanced claims lifecycle knowledge to complex payment integrity and rework scenariosServes as a subject matter expert for claims operations and payment integrity processesLeads small initiatives or workstreams and mentors less experienced analystsServe as a subject matter resource for claims lifecycle impacts related to system changes, vendor outputs, and operational enhancementsAnalyze claims and audit data to identify trends, outliers, and root causes driving incorrect payment or reworkPartner with analytics teams to define reporting requirements and validate outputs used for payment integrity and operational decision-makingTranslate complex claims and system findings into clear business insights for operational and leadership audiencesParticipate in future-state process design and workflow optimization initiativesIdentify opportunities to improve auto-adjudication, reduce manual touchpoints, and strengthen controls within the claims lifecycleLeads enterprise-impact operational analyses and cross-functional initiatives that materially improve claims accuracy, payment integrity outcomes, and provider/member experienceSets analytical direction for complex problem statements; designs measurement approaches, defines success metrics (quality, financial, timeliness), and ensures insights translate into decisions and sustainable operational controlsBuilds and validates advanced analyses (e.g., segmentation, trending, variance drivers, root-cause hypotheses) and partners with Analytics/IT to improve data quality, automate reporting, and enable self-service operational insights. Define the analytical approach, build credible conclusions from messy/complex data and help drive decisionsDrives advanced operational efficiency by identifying and eliminating high-cost manual touchpoints, strengthening upstream adjudication controlsLeads end-to-end process improvement work (problem definition, current-state mapping, root-cause, future-state design, and implementation); develops DLPs/training and partners with stakeholders to drive adoption and measurable outcomesApplies advanced critical thinking to ambiguous, high-risk issues by synthesizing policy/contract/system behavior, evaluating competing options, anticipating downstream impacts, and recommending the best path with mitigation plansProvides thought leadership and coaching across Payment Integrity and Claims Operations; influences leaders and peers through clear recommendations, risk tradeoffs, and executive-ready communicationSupport pre- and post-payment payment integrity activities, including claim selection logic, audit validation, adjustments, and recovery coordinationReview claims, remittances, contracts, policies, and supporting documentation to validate adjudication accuracy and complianceAct as a liaison between Claims Operations, Payment Integrity, Coding, Clinical, IT, and external vendorsRepresent Payment Integrity operational needs in cross-functional forums, backlog prioritization, and system enhancement discussionsAdvance the Rework culture towards one of accountability, collaboration, results-orientation, and most importantly customer centricityProvide in depth rework knowledge to staff in order to strengthen and refine the knowledge within the teamMaintain effective working relationships to ensure teamwork in achieving corporate goalsThe position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirementsSkills4 years of experience in healthcare operations with a strong focus on claims processing, payment integrity, or claims analysis (Level I)6 years of experience in healthcare operations with a strong focus on claims processing, payment integrity, or claims analysis (Level II)8 years of experience in healthcare operations with a strong focus on claims processing, payment integrity, or claims analysis (Level III)Demonstrated experience across the full claim's lifecycle within a healthcare payer environment (All Levels)Experience analyzing claims data, identifying payment issues, and supporting operational or audit-driven resolutions (All Levels)High-School Diploma or GED in general field of study (All Levels)Extensive knowledge of the health insurance industryAdvanced claims and enrollment process and system knowledgeExcellent problem-solving and investigative skillsExcellent relationship building and communication skillsStrong skills in influencing others across teamsStrong written and verbal communicationStrong understanding of healthcare payer claims processes and adjudication logicAnalytical skills with the ability to interpret claims, audit findings, and operational metricsWorking knowledge of medical terminology, coding concepts (ICD‑10, CPT, HCPCS, DRGs), and reimbursement methodologiesProficiency with Excel and claims or reporting systemsThe ability to communicate at all levels, the role will require the analyst to be able to communicate effectively with operations users, a peer network of stakeholders, senior executives, technical resources as well as vendor partnersAnalytical skills to support independent and effective decisionsKnowledge of internal departments and operationsPrioritize tasks and work with multiple priorities, sometimes under limited time constraints. Perseverance in the face of resistance or setbacksCreative judgment and ability to think strategically. Conceptual and tactical planning skillsEffective interpersonal skills and ability to maintain positive working relationship with othersVerbal and written communication skills and the ability to interact professionally with a diverse group, executives, managers, and subject matter expertsSystems research and analysis. Ability to write and present business documentationExtensive experience and judgment necessary to plan and accomplish goalsExperience gaining trust of indirect subordinate staff as well as organizational counterparts to achieve resultsFacilitate and resolve customer requests and inquiries for all levels of management within the CorporationAbility to help others navigate both ambiguous and highly complex system concepts and fostering discussion and problem solving that maintains a focus on customer experienceBuild synergy with a diverse team in an ever changing environmentExperience with synthesizing detailed system information and processes to Executive leadership, both verbally and written, in a fashion that is relatable and accessible by non-technical mindsExperience in payment integrity, claims auditing, coding support, or recovery operationsExperience working with claims adjudication systems, enrollment systems, or payment integrity vendorsExposure to process improvement, rework operations, or system enhancement initiativesAssociate's or Bachelor's Degree in Business, Healthcare Administration, Information Systems, or related field (Level II-III)CPC, CIC, CCS, or similar coding or payment integrity–related credentials (Level II)Lean Six Sigma White/Yellow Belt (Level II-III)Advanced skill in use of office equipment, including copiers, fax machines, scanner and telephonesAdvanced PC proficiencyAdvanced proficiency in spreadsheet, database and word processing softwareAdvanced systems research and analysis expertiseWork with ambiguous and conflicting information while keeping focused on the end goalSolid technical ability and problem solving skillsStrong technical documentation skills and a strong ability to translate technical concepts so that they are easily understood by non-technical stakeholdersAbility to provide mentoring and technical coaching to indirect subordinates and peersBenefitsAt AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work.Our positions are classified as hybrid, onsite or remote.Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per weekHybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per weekHybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per monthOnsite: daily onsite requirement based on the essential functions of the jobRemote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team buildingThis remote work opportunity requires residency, and work to be performed, within the State of Arizona.The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.Company OverviewBlue Cross Blue Shield of Arizona is a non-profit company that offers health insurance and financial services. It was founded in 1939, and is headquartered in Phoenix, Arizona, USA, with a workforce of 1001-5000 employees. Its website is https://www.azblue.com.