Payment Integrity Specialist

Role Description

The role is responsible for managing complex healthcare claim negotiations and ensuring compliance with federal regulations.

• Complete No Surprise Act Negotiations and defend employer groups in the NSA and IDR appeal process.
• Review Itemized Bills and prepare them for physician review including OCR and Spreadsheet entry and formatting.
• Prepares and negotiate settlements with providers.
• Follows up with providers on unsigned settlements.
• Releases claims in the various TPA systems.
• Assist with SCA negotiations.

Qualifications

• At least 5 years of experience in a TPA, Payment Integrity, Revenue Cycle management, and/or coding.
• High school diploma.
• Knowledge of medical terminology and medical billing terminology.
• Experience with Excel, OCR, and strong software and technical proficiency.
• Attention to detail and organizational efficiency.
• Ability to manage multiple stakeholders and deadlines.
• Strong negotiation and dispute resolution skills.
• Self-starter and self-motivated.

Requirements

• Must be able to remain in a stationary position 50% of the time.
• The person in this job needs to occasionally move about inside the office to access office machinery, filing cabinets and meeting facilities.
• Constantly operates a computer and other office productivity machinery, such as copy machine, computer printer, calculator, etc.
• Frequently positions self to maintain files in file cabinets.
• Frequently moves boxes or equipment weighing up to 25 pounds.
• Must communicate information and ideas so others understand. Must be able to exchange accurate information in these situations.
• Must be able to observe details at close range.

Benefits

• Competitive base salary and benefits effective day one.
• Comprehensive medical and dental through our own health solutions (yes, we use what we build).
• Paid Time Off—rest and recharge time is non-negotiable.
• Mental health support, retirement planning, and financial protection.
• Professional development with clear career progression and learning budgets.
• Mission-driven culture where diverse perspectives drive real impact on people's health.