Medical Economics Analyst-Payment Integrity

Location Address:

Compensation Pay Range:

Summary:

Responsibilities:

The Payment Integrity Medical Economics Analyst plays a critical role in identifying, quantifying, and validating medical cost savings opportunities through deep partnership with the Payment Integrity team. This role combines advanced analytics, claims validation, and financial insight to ensure accuracy of payments, integrity of savings initiatives, and alignment to total cost of care (TCOC) objectives.
This individual will leverage enterprise data assets, including claims and provider data, to produce actionable insights, validate recoveries, and support pre- and post-pay integrity initiatives. The role requires strong technical expertise (SQL/SAS), comfort working with large healthcare datasets, and the ability to translate findings into clear financial impact.

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

Qualifications:

• 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
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

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
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

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.