Senior Payment Integrity Specialist
About The Position
The Senior Payment Integrity Specialist is responsible for leading complex payment integrity activities to ensure accurate reimbursement of claims and minimizing financial risk for the health plan. This position provides oversight of third-party payment integrity vendors, performs advanced claims pricing and reimbursement analysis, and supports high-dollar, complex adjustments and recoupments. This individual serves as a subject matter expert, partnering with internal stakeholders to resolve escalated issues, improve payment accuracy, and strengthen payment integrity controls while ensuring compliance with contractual and regulatory requirements.
Requirements
- High School diploma or GED
- At least 3–5 years of healthcare claims processing experience, including adjustments or payment research
- Advanced understanding of claims pricing, reimbursement methodologies, and payment policies
- Proficiency with claims systems and Microsoft Office applications
- Strong attention to detail and accuracy
- Effective written and verbal communication
- Strong organizational and time-management skills
- Ability to work independently within defined guidelines
- Ability to evaluate complex and high-dollar payment integrity findings
- Working knowledge of claim edits, payment methodologies, and adjustment workflows
- Knowledge of Centers for Medicare & Medicaid Services (CMS) guidelines and payer payment policies
Nice To Haves
- Associates degree or higher
- Experience in payment integrity, recovery auditing, or overpayment recovery
- Experience working with payment integrity or audit vendors
Responsibilities
- Serve as subject matter expert for vendor-supported payment integrity activities.
- Perform independent analysis of complex pricing and reimbursement scenarios.
- Resolve discrepancies related to Diagnosis-Related Groups (DRG), Ambulatory Payment Classifications (APC), case rates, stop-loss, and fee schedules.
- Determine appropriateness of recoupment actions for complex or high-dollar cases.
- Support resolution of provider disputes and appeals related to payment integrity findings.
- Identify systemic payment issues and recommend corrective actions.
- Partner with Claims, Configuration, Contracting, and Compliance to prevent recurring errors.
- Lead initiatives to improve payment accuracy and recovery outcomes.
- Provide guidance and training to Payment Integrity team.
- Serve as escalation point for complex or sensitive issues.
Benefits
- Comprehensive Health, Vision, and Dental Coverage
- 401(k) Savings Plan with company match and immediate vesting
- Paid Time Off (PTO)
- 9 Paid Holidays annually plus a Floating Holiday to use as you choose
- Tuition Assistance
- Flexible Spending Accounts
- Healthcare Reimbursement Account
- Paid Parental Leave
- Community Service Time Off
- Life Insurance and Disability Coverage
- Employee Wellness Program
- Training and Development Programs to develop new skills and reach career goals
- Employee Assistance Program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
