Payment Integrity Recovery Specialist I

Solis Health Plans

2d

About The Position

The Payment Integrity Recovery Specialist I is responsible for identifying, auditing, and recovering claims overpayments. This role partners with internal stakeholders, providers, and external vendors to ensure accurate claims payment and compliance with contractual, federal, and state requirements. The specialist performs detailed research and analysis, facilitates recoveries, and supports resolution of complex overpayment issues while maintaining strong provider relationships.

Requirements

• Minimum of 4 years of relevant experience in healthcare claims, payment integrity, or recovery operations.
• Strong knowledge of managed care claims processing and reimbursement methodologies.
• Experience interpreting provider contracts and identifying payment discrepancies.
• Familiarity with federal and state healthcare regulations.
• Strong analytical and problem-solving skills with attention to detail.
• Effective communication and negotiation skills, particularly with providers.
• Ability to manage multiple cases and meet strict deadlines.
• Proficiency in claims systems, data analysis tools, and reporting platforms.
• Strong organizational and documentation skills.
• Commitment to accuracy, compliance, and customer satisfaction.

Nice To Haves

• At least 3 years of cost containment experience preferred.

Responsibilities

• Audit paid medical claims to identify overpayments using system queries, specialized reports, and manual research techniques
• Conduct comprehensive research, analysis, and documentation of overpayment cases
• Initiate and manage recovery efforts, including collection activities for overpayments and negative balance accounts
• Collaborate with provider organizations to communicate findings and resolve overpayment issues
• Interpret provider contracts to identify recovery opportunities and ensure compliance with contractual terms
• Partner with contract management teams to address and correct reimbursement or contractual discrepancies
• Serve as a liaison between cost containment teams, health plans, and high-profile providers to ensure timely and satisfactory resolution of recoveries
• Investigate and resolve moderately complex overpayment cases and special projects
• Assist with the review and resolution of state complaints related to overpayments or negative balances within mandated timelines
• Coordinate with recovery and collection vendors to validate identified overpayments and review vendor invoices for accuracy
• Analyze claims data and trends to detect payment errors and recommend process improvements
• Provide feedback to improve audit queries, reporting tools, and recovery processes
• Ensure all activities comply with company policies and applicable federal and state regulations.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: No Education Listed
• Number of Employees: 11-50 employees