Payment Cycle Analyst II

CareSource

. Define clinical and payment policy requirements for configuration of clinical editing systems .

Posted 9/22/2026full-timeRemote • United StatesMid-LevelSenior💰 $62,700 - $100,400 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical and payment policy analysis, including reimbursement policy claim edits and clinical editing software. Proficient in data analysis, claims processing, and regulatory compliance within managed care environments.

Highest-signal resume keywords

Clinical Editing Software ExperienceICD-9/ICD-10, CPT, HCPC, REV, DRG, RUG KnowledgeData Analysis and Trending SkillsStrong Written and Verbal Communication SkillsCertified Medical Coder

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Data AnalysisClaims ProcessingClinical EditingReimbursement Policy AnalysisConfiguration DesignRegulatory CompliancePayment Policy DocumentationError IdentificationSystem ValidationPolicy Development

Soft Skills

Strong Communication SkillsAbility to Work IndependentlyTeam Collaboration

Tools & Technologies

Microsoft SuiteFacetsReporting Packages

Certifications & Qualifications

Certified Medical Coder

Industry Keywords

Health Plan ExperienceClaims OperationsManaged CareHIPAA Transaction CodesCMS GuidelinesAffordable Care Act

About the role

Key responsibilities & impact

Define clinical and payment policy requirements for configuration of clinical editing systems
Research potential reimbursement policy claim edits, including support sourcing, data analysis, regulatory consistency, and network impact
Research claim results to identify errors and discrepancies related to clinical edits, coding, payment policies, fee schedules, and rates
Conduct systemic and targeted analysis to identify reimbursement errors and root causes
Prepare, review, and obtain approval for clinical and payment policy analysis and documentation before implementation
Provide input to UAT and conduct post-production validation
Create written and oral communications summarizing findings and fact-based recommendations for providers, provider associations, and Health Partner Managers
Document open issues, configuration design, and final resolutions
Review and interpret regulatory items and deliver required updates
Support system change policy initiatives, provide updates in payment policy meetings, and present to stakeholders
Monitor configuration and claims SOPs for payment accuracy
Assist in developing policies and procedures for claims processing, COB, appeals, and adjustments
Ensure payment policies and decisions are documented and support provider education activities with the Health Partner team
Perform other duties as requested

Requirements

What you’ll need

Bachelor’s degree or equivalent years of relevant work experience is required
Minimum of three (3) years of health plan experience is required or equivalent experience with provider coding and claim payment policies
Experience working with clinical editing software is preferred
Advanced proficiency in Microsoft Suite, including Word, Excel, Access, and Visio
Strong computer skills and abilities in Facets
Understanding of claims operations, configuration, and clinical editing related to managed care
Strong working knowledge of ICD-9/ICD-10, CPT, HCPC, REV, DRG, and RUG code sets
Knowledge of HIPAA Transaction Codes
Data analysis and trending skills
Strong written and verbal communication skills
Strong claims processing edits and logic knowledge
Familiarity with CMS guidelines, HIPAA, and the Affordable Care Act
Familiarity with reporting packages and running system reports
Certified Medical Coder preferred
Ability to work independently and within a team environment
Occasional travel of up to 10% may be required

Benefits

Comp & perks

Bonus tied to company and individual performance may be available
Comprehensive total rewards package
Occasional travel to meetings, training, and conferences