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

ABOUT THE TEAM
About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model:

At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose – whether working in the office or through a hybrid approach – by providing clear expectations while respecting the diverse needs of our workforce.

Two Ways of Working:

• Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above). Exceptions:

o Member-facing and approved out-of-state roles remain remote.

o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.

o For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

• On-Site: Work from a business unit-approved office an average of four (4) or more days a week.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.