Pricing Resolution Processor II
About The Position
MedReview is seeking a Pricing Resolution Processor II to join its Payment Integrity Operations team. The role reviews, groups, and prices routine healthcare facility claims to identify potential overpayments and support accurate reimbursement. The processor applies client-specific reimbursement methodologies, payer requirements, regulatory guidelines, and internal operational standards to make accurate and timely claim pricing decisions. The role requires healthcare claims processing experience, analytical skills, and attention to detail. It involves evaluating claim information, identifying discrepancies, validating data, and ensuring compliance with reimbursement policies and contractual obligations while meeting productivity and quality standards in a high-volume environment. This is a full-time position that may be remote or office-based depending on operational needs. Remote workers must maintain a secure workspace that protects PHI and HIPAA-regulated data. The work environment is fast-paced and production-oriented, with extensive computer use, claims review, data validation, pricing analysis, and electronic communication.
Requirements
- High school diploma or equivalent.
- 1–3 years of experience in healthcare claims processing, healthcare billing, reimbursement, revenue cycle, or related healthcare operations.
- Working knowledge of ICD-10 diagnosis coding, CPT coding, Revenue Codes, medical terminology, and the healthcare claims adjudication process.
- Strong analytical and problem-solving skills, including the ability to make sound decisions based on available claim information.
- Ability to learn and navigate multiple systems and applications simultaneously.
- Excellent written and verbal communication skills.
- Strong organizational skills and ability to prioritize work, manage competing deadlines, and handle a high-volume workload while maintaining quality and productivity.
- High attention to detail and commitment to data accuracy.
- Proficiency with Microsoft Office applications, including Outlook, Excel, and Word.
- Ability to work independently with minimal supervision.
- Ability to remain calm and professional in a fast-paced environment with frequent interruptions.
- For remote work: high-speed internet connection (100 Mbps per person recommended) with secure Wi-Fi access; a secure, dedicated workspace with minimal interruptions; and ability to maintain PHI confidentiality and comply with HIPAA requirements.
- Ability to sit and work at a computer for extended periods and utilize multiple systems and applications simultaneously throughout the workday.
Nice To Haves
- Associate degree in Healthcare Administration, Business Administration, Health Information Management, or a related field.
- Experience with healthcare payment integrity operations.
- Experience reviewing and pricing facility claims.
- Familiarity with payer reimbursement methodologies and provider contract language.
- Experience working with health plans, third-party administrators, or healthcare payment integrity organizations.
- Knowledge of Medicare, Medicaid, and Commercial healthcare reimbursement principles.
Responsibilities
- Review assigned healthcare claims for completeness, accuracy, and eligibility for review.
- Validate claim information and supporting documentation before pricing activities begin.
- Analyze claim details to confirm required information is submitted and documented appropriately.
- Identify missing, inaccurate, or inconsistent claim data and initiate resolution steps.
- Manage assigned workloads and turnaround expectations while maintaining accuracy.
- Group facility claims using client and internal systems in accordance with established methodologies.
- Apply reimbursement methodologies based on client requirements, regulatory guidance, and contractual obligations.
- Price claims accurately and consistently according to payer-specific guidelines.
- Review claims to identify potential overpayments and reimbursement discrepancies.
- Use internal applications and client platforms for pricing and claim review activities.
- Follow payer contract requirements, regulatory standards, and internal operational procedures.
- Validate data entry and pricing calculations and monitor claim outcomes to identify and resolve discrepancies.
- Maintain complete and accurate documentation supporting pricing determinations and claim processing.
- Meet departmental productivity, quality, accuracy, and turnaround-time expectations.
- Escalate complex claim issues, discrepancies, or reimbursement concerns when appropriate.
- Use sound judgment to determine when management review is necessary.
- Collaborate with internal operational teams to support claim pricing accuracy and workflow efficiency.
- Participate in process improvement initiatives, training programs, and departmental meetings.
- Support additional duties and special projects as assigned.
Benefits
- Comprehensive medical, dental, and vision coverage.
- 401(k) with employer match.
- Generous paid time off and paid holidays.
- Flexible spending accounts (FSA) and commuter benefits.
- Professional development and continuing education opportunities.
- LinkedIn Learning access and ongoing training programs.
- Employee wellness programs.
- Collaborative and mission-driven work environment.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
