Claims Payment Integrity Specialist, Health Plan
About The Position
The Claims Payment Integrity Specialist identifies, prevents, and recovers improper claim payments across Medicare, Medicaid, Exchange, group, and TPA lines of business. The role helps protect plan assets by ensuring claims are paid accurately and in accordance with coding standards, provider contracts, regulatory requirements, and internal policies. The specialist conducts pre- and post-payment audits, analyzes claims data for trends and risks, and supports payment integrity initiatives and new claim-editing solutions. The role also coordinates overpayment recovery, prepares audit communications, supports appeals and provider inquiries, and works with internal teams and external partners to address root causes and prevent future errors. The specialist documents audit findings and contributes to performance reporting, regulatory audits, and other program integrity initiatives.
Requirements
- Associate's degree in Healthcare Administration, Business, Finance, or a related field, or equivalent relevant experience or a combination of higher education and relevant experience.
- At least two years of experience in claims, payment integrity, audit, program integrity, or healthcare operations.
- Experience working with multiple lines of business, including Medicare, Medicaid, Commercial, Exchange, and/or TPA.
- Proficiency with claims systems and Microsoft Office tools, including Excel, Word, and Outlook.
- Strong understanding of healthcare claims processing, reimbursement methodologies, and benefit structures.
- Working knowledge of Medicare, Medicaid, commercial, Exchange, and TPA payment models.
- Ability to interpret provider contracts, fee schedules, and medical policies.
Nice To Haves
- Bachelor’s degree.
- Experience with claims data analytics or recovery vendor management.
- Knowledge of CMS and state Medicaid program integrity expectations.
- Certified Professional Coder (CPC), Certified Payment Integrity Professional (CPIP), or similar certification.
Responsibilities
- Conduct pre- or post-payment claim reviews to identify overpayments, underpayments, duplicate payments, coding errors, and contractual discrepancies across lines of business.
- Analyze claims using data analytics, reporting tools, and audit methodologies to identify trends, anomalies, and payment risks.
- Lead implementation of initiatives addressing incorrect payment trends or introducing claim-editing solutions.
- Validate claims compliance with CMS, state Medicaid agencies, ACA, ERISA, and other applicable requirements.
- Apply benefit, provider contract, fee schedule, reimbursement methodology, and medical policy interpretations to payment integrity work.
- Initiate recovery actions for identified overpayments, coordinating with providers, recovery vendors, or internal adjustment processes.
- Prepare clear, accurate, and compliant communications explaining audit findings and recovery rationales.
- Support appeals, disputes, and provider inquiries related to payment integrity findings and functions.
- Partner with Claims Operations, Provider Relations, Compliance, Legal, Configuration, and Finance to resolve root causes of payment errors.
- Recommend improvements to claims configuration, policies, and workflows, and support corrective actions and preventive controls.
- Work with leadership to understand business needs and recommend strategies to maximize medical and administrative savings and minimize payment errors.
- Maintain detailed documentation of audit activities, findings, and outcomes.
- Contribute to reporting on payment integrity performance, recoveries, and identified risk areas.
- Participate in special projects, regulatory audits, and program integrity initiatives as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
