Payment Integrity Specialist

Cityblock Health

1d•$70,000 - $82,000

About The Position

The Payment Integrity Specialist ensures that the claims and payments flowing through Cityblock’s value-based arrangements are accurate, appropriate, and compliant. Working across the claims and reimbursement lifecycle, the role identifies payment discrepancies — overpayments, underpayments, and improper payments — determines their root causes, and drives both recovery and prevention. Cityblock operates in risk-bearing, value-based arrangements with managed care organizations serving complex Medicaid, Medicare Advantage, and Dually Eligible populations. Payment integrity therefore spans two sides: ensuring Cityblock is reimbursed correctly by payers under capitation, kick-payment, and value-based settlements, and ensuring the medical claims that count against Cityblock’s cost and performance are accurate and free of error, waste, or abuse; all adhering to the value based contracts supporting the partnerships. This is a detail-intensive, analytical role that combines claims and coding knowledge, data analysis, and command of CMS and state Medicaid reimbursement rules. Success requires precision, an investigative mindset, and the ability to translate findings into recoveries and durable process improvements in partnership with finance, actuarial, partner success, and clinical teams.

Requirements

Bachelor’s degree in finance, healthcare administration, business, health information management, or a related field; relevant certification (e.g., CPC, CFE, AHFI) a plus.
3+ years in payment integrity, claims auditing, revenue cycle, medical economics, health-plan or provider claims analysis.
Working knowledge of the healthcare claims lifecycle and coding systems (CPT, HCPCS, ICD-10, DRG), and familiarity with CMS and state Medicaid reimbursement rules.
Exposure to value-based, capitation, or managed-care arrangements strongly preferred; Medicaid experience a plus.
Strong Excel skills; SQL or other claims-data querying strongly preferred.
Demonstrated ability to present findings clearly to both technical and non-technical stakeholders.

Nice To Haves

Relevant certification (e.g., CPC, CFE, AHFI)
Medicaid experience a plus.

Responsibilities

Review claims and encounters against contract terms, policy, CMS and Medicaid guidelines, and coding standards to confirm accuracy.
Identify overpayments, underpayments, duplicate payments, and improper payments, documenting findings clearly and defensibly.
Reconcile expected reimbursement against actual payments across capitation, value-based, kick-payment, and fee-for-service arrangements, and investigate variances.
Help define, validate, and refine payment-integrity edits and rules (pre-pay edits and post-pay analytics) to catch errors earlier in the process.
Determine the systemic sources of payment errors and recommend process, configuration, or contracting fixes that prevent recurrence.
Partner with stakeholders to operationalize corrective actions and track their impact over time.
Surface potential fraud, waste, and abuse patterns in claims data and escalate them in line with policy to Actuary, Finance, Partner Success, and Payor teams.
Ensure reviews and recoveries align with CMS, state Medicaid, and contract-specific requirements.
Maintain rigorous documentation of findings, methodologies, and recoveries to support investigation.
Analyze claims, encounter, and payment data to identify trends, quantify financial impact, and prioritize the highest-value opportunities.
Build and maintain reports and dashboards that track payment-integrity findings, recoveries, and prevention outcomes.
Collaborate with finance, actuarial, market, partner success teams to resolve issues and align on standards.