Payment Integrity Specialist

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

📋 Description

• Oversee both internal and external audits concerning claims, payments, and refunds.

• Perform regular audits on payer contracts and payment activities to ensure adherence to MFN laws and contract stipulations.

• Detect and report any inconsistencies in payment rates, coding, and authorization processes.

• Examine and process refund requests from both payers and patients.

• Guarantee the timely and precise posting of payments and the resolution of denials.

• Maintain comprehensive records of transactions and audit results.

• Confirm that payments are consistent with negotiated payer contracts and MFN regulations.

• Work in conjunction with legal and contracting teams to analyze and apply MFN rules.

• Aid in payer configuration assessments and contract audits.

• Stay informed about federal and state regulations affecting payment integrity, including MFN laws.

• Ensure that audit processes and documentation comply with established standards.

• Assist in formulating responses to regulatory inquiries and payer audits.

• Collaborate with appeals, credentialing, and market access teams to address payment issues.

• Offer insights and suggestions for process enhancements to operational teams.

• Engage in payer meetings and internal workgroups to optimize audit and payment processes.

⛳️ Requirements

• A Bachelor’s degree in healthcare administration, finance, or a related discipline (or equivalent experience).

• 3–5 years of experience in medical billing, payment integrity, or auditing of payer contracts.

• Strong grasp of MFN laws, payer policies, and healthcare reimbursement models.

• Proficiency in claims management systems and data analytics tools.

• Outstanding attention to detail, analytical skills, and problem-solving capabilities.

• Excellent communication and documentation skills.

• CPCS or a similar certification is preferred.

🏝️ Benefits

• Competitive salary and benefits package.

• Health insurance coverage.

• Paid time off.

• Flexible work arrangements.

• Opportunities for professional development.