Business Analyst, Principal - Payment Integrity

Your Role

The Promise Payment Integrity team leads the research and identification of financial integrity opportunities for Medi-Cal, not limited to the recoupment of provider overpayments, reinforce compliant claims payment processes, and ensure accurate revenue oversight and reconciliation. The Principal Business Analyst will report to the Director of Medi-Cal Performance Optimization. In this role you will blend deep claims data expertise with Medicaid/Medi-Cal policy know-how to deliver near-term recoveries and long-term solutions. 

Your Work

In this role, you will:

• Develop and conduct evaluations and studies within limited time frames and produce analyses that are easy for non-technical persons to understand
• Apply advanced statistical methods, advanced analytics and modeling techniques, visualization techniques, and advanced programming to innovate our products and services
• Identify how our customers are using our products to make strategic decisions and generate/implement ideas to improve our products and services to allow even better decision support
• Identify & size opportunities: Mine medical claims (header/line), remits, authorization, and provider data to detect overpayment patterns (e.g., duplicate, unbundling, DRG upcoding, place-of-service, COB, retro eligibility, NCCI edits)
• Lead recoveries end-to-end: Validate hypotheses, quantify impact, document case logic, and route to recovery—letters, offsets, refund processing, and tracking—ensuring timely, compliant collections
• Root-cause & fix: Perform RCA on adjudication errors (pricing, benefits, provider setup, code edits, COB, policy gaps) and drive corrective actions in Facets configuration, claims editing, or business process changes (UAT + production readiness)
• Govern vendor & internal programs: Own the day-to-day of assigned PI programs (internal and vendor-supported), monitor KPIs, backlog, and quality, and escalate issues; convert one-off "finds" into durable edit/rules
• Regulatory alignment: Ensure recoveries and edits align to Medicaid/Medi-Cal rules and plan contracts; partner with Compliance/Legal on policy interpretation and provider communications
• Cross-functional leadership: Partner with Claims Ops, Provider Contracting, Medical Management, SIU/FWA, and Finance on implementation, appeals, and provider education; present results to leadership
• Reporting & storytelling: Build dashboards and narrative readouts: opportunity pipeline, identified/validated/recovered, yield, aging, and fix adoption

Your Knowledge and Experience

• Requires mastery level knowledge of job area typically obtained through advanced education combined with experience. May have deep knowledge of project management 
• Requires a bachelors degree or equivalent experience 
• Requires at least 10 years of prior relevant experience 
• Requires SQL expertise; strong Excel; experience with a viz tool (Power BI/Tableau) preferred
• Requires hands-on experience with claims systems (preferably Facets) - benefit, pricing, provider/network, and code-edit constructs; able to partner on config and UAT
• Medical Coding knowledge: working mastery of ICD-10-CM/PCS, CPT/HCPCS, DRG, modifiers, NCCI, POS, revenue codes. Certifications (CPC, COC, CPMA) is preferred
• Medicaid/Medi-Cal payment policy familiarity (coordination of benefits, retro eligibility, rate/benefit nuances, prior auth, state policy bulletins)  is preferred
• Prior experience in a California plan with Medi-Cal (DHCS) lines of business, exposure to vendor PI programs (post-pay, pre-pay, DRG validation, coding audits) and FWA/SIU collaboration is preferred