Payment Integrity Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct audits on payer claims across various lines of business (commercial, FEP, Medicaid, Medicare) to identify improper payments and opportunities for recovery.

• Perform in-depth analysis of claims data to uncover root causes of improper payments and establish robust audit findings.

• Achieve or surpass a monthly dollars-identified target once assigned to a client (the goal varies by client and audit type; a ramp-up period is expected during onboarding).

• Uphold a high standard of quality on all identified dollars, minimizing false positives to ensure findings withstand client scrutiny.

• Develop new audit concepts and recovery strategies based on patterns observed in the data (aim for at least one new concept each month).

• Provide timely support to key stakeholders with client deliverables, including audit outcomes and necessary documentation.

• Utilize knowledge of payment integrity and claims processing across various payers and claim systems as engagements evolve.

• Contribute to the collective knowledge of the team (trends, methodologies, and audit playbooks) as our capabilities expand.

⛳️ Requirements

• A minimum of 2 years of experience working with a payer or in a payment integrity/audit vendor role.

• Practical experience in claims processing and payment integrity auditing.

• Exposure to multiple lines of business (commercial, FEP, Medicaid, Medicare); a broad understanding is preferred over deep expertise in a single line.

• Strong analytical skills: you can identify significant issues in the data and trace them to their root causes.

• Proficiency with Excel and general software; you quickly adapt to new claims systems (client-specific training will be provided).

• A history of achieving metric-driven, time-sensitive objectives while maintaining composure under monthly targets.

• High integrity and sound judgment; you confidently make decisions on findings and stand by them.

• Ability to work independently and take ownership; you do not require management to navigate your workload.

• Must be authorized to work in the U.S. and be U.S.-based (this role involves handling PHI and cannot be performed offshore).

🏝️ Benefits

• Health insurance

• Paid time off

• Flexible work arrangements

• Professional development opportunities