Revenue Integrity Analyst (Onsite, In-Person in Laguna Hills, CA)

Job Summary
AmeriPharma is seeking a data-driven Revenue Integrity Analyst to serve as the engine behind our Revenue Integrity department. This role is critical in identifying financial "leakage" across our specialty pharmacy and infusion service lines. You will be responsible for analyzing raw 835/837 claim data, identifying payment variances, and providing the Executive Team with the "Expected vs. Actual" insights needed to drive our national payor strategy.

The ideal candidate possesses a "detective" mindset, capable of navigating complex HCPCS J-code unit conversions and translating clinical documentation gaps into financial ROI opportunities.  

Schedule Details 

Location: On-Site, Laguna Hills, CA. 

Hours: Monday-Friday, 8:00 AM - 4:30 PM or 8:30 AM - 5:00 PM (schedule can be discussed further during the interview process)

Duties & Responsibilities
• Variance & Underpayment Analysis: Conduct deep-dive audits of payer remittances to identify discrepancies between contracted/SCA rates and actual payments.
• HCPCS & Unit Integrity: Audit high-cost specialty drug claims (IVIG, TPN, Biologics) to ensure billing units match the clinical dose administered, identifying trends in unit-level underpayments.

• 835/837 Raw Data Modeling: Extract and manipulate large datasets from billing systems to build quarterly "Actual vs. Expected" reimbursement reports for the VP of Revenue Cycle.
• Denial Root Cause Analysis: Assist in categorizing denial trends by Payer and CARC (Claim Adjustment Reason Code) to pinpoint systemic front-end or clinical documentation failures.
• Debit/Credit Reconciliation: Audit AR adjustments, identifying where debit adjustments are required due to OON payer behavior or where credit balances need reconciliation.
• Contract Performance Tracking: Partner with the Director of Payer Contracting to model the financial impact of new contract terms and site-of-service optimization strategies.

Required Qualifications
• Education: Bachelor’s degree in finance, Accounting, Health Administration, or related experience in other healthcare organizations under the same role and responsibilities.
• Experience: 3–5 years of experience in Healthcare Finance or RCM Analysis, specifically within Specialty Pharmacy, Home Infusion, or high-acuity medical services.
• Technical Mastery: * Advanced Excel: (Pivot Tables, Power Query, VLOOKUP/XLOOKUP, and complex financial modeling).
    Data Visualization: Experience with Tableau, Power BI, or integrated RCM dashboards.
    System Knowledge: Familiarity with Medicare DDE, clearinghouse portals (Availity, Waystar), and EMR/EHR financial modules.

• Analytical Mindset: Proven ability to spot patterns in "noisy" data and translate them into actionable business recommendations.

• Prior work experience in a healthcare organization is a must.  

Core Competencies
• Precision: High attention to detail regarding J-code unit definitions (e.g., 1 unit = 10mg vs. 1 unit = 100mg).
• Communication: Ability to present complex financial variances to non-financial stakeholders, including clinical and intake teams.
• Proactivity: A "go-getter" who doesn't wait for reports to be requested but identifies risks and opportunities through independent data exploration.

Performance Success Metrics
• Net Revenue Realization: Assist to reducing the delta between "Expected" and "Actual" reimbursement.
• DSO Reduction: Help to Identify bottlenecks in the claim lifecycle to accelerate cash flow.
• Audit Accuracy: Zero-error rate in identifying J-code unit mismatches for Top Payor claims.