Payment Integrity Operations Analyst III - Remote AZ

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions. At 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. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements: Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week Hybrid 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 month Onsite: daily onsite requirement based on the essential functions of the job Remote: 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 building Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week. This remote work opportunity requires residency, and work to be performed, within the State of Arizona. PURPOSE OF THE JOB The Payment Integrity Operations Analyst is responsible for supporting payment accuracy and operational effectiveness across the healthcare claims lifecycle, from intake and adjudication through post-payment review, recovery, and provider/member resolution. This role partners closely with Claims Operations, Payment Integrity, Analytics, Clinical/Coding SMEs, and Technology teams to identify claim processing issues, payment risks, and rework opportunities. The analyst applies deep claims knowledge to analyze workflows, validate outcomes, support audits and recoveries, and drive sustainable improvements that reduce provider abrasion, improve member experience, and protect plan assets. Key Focus Areas End-to-end claims lifecycle expertise (pre‑adjudication, adjudication, post‑payment, adjustments, recoveries) Payment Integrity operations and audit support Claims rework and root-cause analysis Data analysis and operational reporting Cross-functional collaboration and issue resolution QUALIFICATIONS REQUIRED QUALIFICATIONS Required Work Experience 4 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) Required Education High-School Diploma or GED in general field of study (All Levels) Required Licenses N/A Required Certifications N/A PREFERRED QUALIFICATIONS Preferred Work Experience (All Levels) Experience in payment integrity, claims auditing, coding support, or recovery operations Experience working with claims adjudication systems, enrollment systems, or payment integrity vendors Exposure to process improvement, rework operations, or system enhancement initiatives Preferred Education Associate’s or Bachelor’s Degree in Business, Healthcare Administration, Information Systems, or related field (Level II-III) Preferred Licenses N/A Preferred Certifications CPC, CIC, CCS, or similar coding or payment integrity–related credentials (Level II) Lean Six Sigma White/Yellow Belt (Level II-III) ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES Level I Demonstrates solid working knowledge of claims processing and payment integrity concepts. Independently analyzes claims issues and supports audits, rework, and reporting. Requires limited guidance for routine to moderately complex work. Analyze claims processing workflows to identify payment risks, rework drivers, and systemic defects across all lines of business. Support or lead claims rework and adjustment activities, ensuring accurate resolution and timely completion. Communicate complex claims and payment integrity topics clearly to both technical and non-technical stakeholders. Level II Applies advanced claims lifecycle knowledge to complex payment integrity and rework scenarios. Serves as a subject matter expert for claims operations and payment integrity processes. Leads small initiatives or workstreams and mentors less experienced analysts. Serve as a subject matter resource for claims lifecycle impacts related to system changes, vendor outputs, and operational enhancements. Analyze claims and audit data to identify trends, outliers, and root causes driving incorrect payment or rework. Partner with analytics teams to define reporting requirements and validate outputs used for payment integrity and operational decision-making. Translate complex claims and system findings into clear business insights for operational and leadership audiences. Participate in future-state process design and workflow optimization initiatives. Identify opportunities to improve auto-adjudication, reduce manual touchpoints, and strengthen controls within the claims lifecycle. Level III Leads enterprise-impact operational analyses and cross-functional initiatives that materially improve claims accuracy, payment integrity outcomes, and provider/member experience. Sets analytical direction for complex problem statements; designs measurement approaches, defines success metrics (quality, financial, timeliness), and ensures insights translate into decisions and sustainable operational controls. Builds 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 decisions. Drives advanced operational efficiency by identifying and eliminating high-cost manual touchpoints, strengthening upstream adjudication controls. Leads 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 outcomes. Applies 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 plans. Provides thought leadership and coaching across Payment Integrity and Claims Operations; influences leaders and peers through clear recommendations, risk tradeoffs, and executive-ready communication. ALL LEVELS: Support pre- and post-payment payment integrity activities, including claim selection logic, audit validation, adjustments, and recovery coordination. Review claims, remittances, contracts, policies, and supporting documentation to validate adjudication accuracy and compliance. Act as a liaison between Claims Operations, Payment Integrity, Coding, Clinical, IT, and external vendors. Represent Payment Integrity operational needs in cross-functional forums, backlog prioritization, and system enhancement discussions. Advance the Rework culture towards one of accountability, collaboration, results-orientation, and most importantly customer centricity. Provide in depth rework knowledge to staff in order to strengthen and refine the knowledge within the team. Maintain effective working relationships to ensure teamwork in achieving corporate goals. 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. COMPETENCIES REQUIRED COMPETENCIES Required Job Skills (All Levels) Extensive knowledge of the health insurance industry Advanced claims and enrollment process and system knowledge Excellent problem-solving and investigative skills Excellent relationship building and communication skills Strong skills in influencing others across teams Strong written and verbal communication Strong understanding of healthcare payer claims processes and adjudication logic Analytical skills with the ability to interpret claims, audit findings, and operational metrics Working knowledge of medical terminology, coding concepts (ICD‑10, CPT, HCPCS, DRGs), and reimbursement methodologies Proficiency with Excel and claims or reporting systems Required Professional Competencies (All Levels) The 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 partners. Analytical skills to support independent and effective decisions Knowledge of internal departments and operations Prioritize tasks and work with multiple priorities, sometimes under limited time constraints. Perseverance in the face of resistance or setbacks. Creative judgment and ability to think strategically. Conceptual and tactical planning skills. Effective interpersonal skills and ability to maintain positive working relationship with others. Verbal and written communication skills and the ability to interact professionally with a diverse group, executives, managers, and subject matter experts. Systems research and analysis. Ability to write and present business documentation. Extensive experience and judgment necessary to plan and accomplish goals. Required Leadership Experience and Competencies (All Levels) Experience gaining trust of indirect subordinate staff as well as organizational counterparts to achieve results. Facilitate and resolve customer requests and inquiries for all levels of management within the Corporation. Ability to help others navigate both ambiguous and highly complex system concepts and fostering discussion and problem solving that maintains a focus on customer experience. Build synergy with a diverse team in an ever changing environment. Experience 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 minds PREFERRED COMPETENCIES Preferred Job Skills (All Levels) Advanced skill in use of office equipment, including copiers, fax machines, scanner and telephones Advanced PC proficiency Advanced proficiency in spreadsheet, database and word processing software Preferred Professional Competencies (All Levels) Advanced systems research and analysis expertise Work with ambiguous and conflicting information while keeping focused on the end goal Solid technical ability and problem solving skills Strong technical documentation skills and a strong ability to translate technical concepts so that they are easily understood by non-technical stakeholders Preferred Leadership Experience and Competencies (Level II-III) Ability to provide mentoring and technical coaching to indirect subordinates and peers Our Commitment AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group. Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.