Payment Integrity Specialist

Job Description:

Claim & Payment Accuracy Review

• Payment Audits: Review claims and encounters against contract terms, policy, CMS and Medicaid guidelines, and coding standards to confirm accuracy.

• Discrepancy Identification: Identify overpayments, underpayments, duplicate payments, and improper payments, documenting findings clearly and defensibly.

• Expected vs. Actual Reimbursement: Reconcile expected reimbursement against actual payments across capitation, value-based, kick-payment, and fee-for-service arrangements, and investigate variances.
   

Root-Cause Analysis & Prevention

• Edit & Rule Logic: Help define, validate, and refine payment-integrity edits and rules (pre-pay edits and post-pay analytics) to catch errors earlier in the process.

• Root-Cause Analysis: Determine the systemic sources of payment errors and recommend process, configuration, or contracting fixes that prevent recurrence.

• Process Improvement: Partner with stakeholders to operationalize corrective actions and track their impact over time.
   

Fraud, Waste & Abuse and Compliance

• FWA Detection: 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.

• Regulatory & Contract Compliance: Ensure reviews and recoveries align with CMS, state Medicaid, and contract-specific requirements.

• Audit-Ready Documentation: Maintain rigorous documentation of findings, methodologies, and recoveries to support investigation.

Analytics, Reporting & Collaboration

• Data Analysis: Analyze claims, encounter, and payment data to identify trends, quantify financial impact, and prioritize the highest-value opportunities.

• Reporting: Build and maintain reports and dashboards that track payment-integrity findings, recoveries, and prevention outcomes.

• Cross-Functional Partnership: Collaborate with finance, actuarial, market, partner success teams to resolve issues and align on standards.
   

• 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.

• Claims & Coding Knowledge: Working knowledge of the healthcare claims lifecycle and coding systems (CPT, HCPCS, ICD-10, DRG), and familiarity with CMS and state Medicaid reimbursement rules.

• Value-Based & Managed Care: Exposure to value-based, capitation, or managed-care arrangements strongly preferred; Medicaid experience a plus.

• Analytical Tools: Strong Excel skills; SQL or other claims-data querying strongly preferred.

• Communication: Demonstrated ability to present findings clearly to both technical and non-technical stakeholders.

We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for health insurance, life insurance, retirement benefits, participation in the company’s equity program, paid time off, including vacation and sick leave. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location. The expected salary range for this position is: 

Cityblock values diversity as a core tenet of the work we do and the populations we serve. We are an equal opportunity employer, indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.