Medical Claims Repricer

Medical Claims Repricer/Analyst

Claims repricing is the process of reviewing and adjusting healthcare claims to ensure that the billed charges align with statutory and/or contracted rates between providers and payers. This process helps control costs by applying discounts, fee schedules, statutory limits or negotiated rates to the original charges before payment is made. Claims repricing professionals analyze claims data and ensure compliance with contractual and statutory requirements. The goal at MedHealth is to ensure the most favorable and accurate rates for taxpayers and prevent overpayment or underpayment for healthcare services.

Our Medical Claims Repricer/Analyst is responsible for reviewing and processing hospital and provider claims to ensure accuracy, completeness, and compliance with contracts and statutory terms. The role negotiates favorable rates where they don't already exist and otherwise determines the most favorable appropriate reimbursement based on statutory, contract, and negotiated rates. The Medical Claims Repricer/Analyst also resolves discrepancies, communicates with healthcare providers, and follows healthcare regulations and billing procedures.

This role ensures medical claims are reviewed, repriced, resolved accurately and then timely approved for payment. The Medical Claims Repricer/Analyst compares billed charges against applicable statutory limits, contracted rates, custom fee schedules, discounts, and negotiated terms to identify the most favorable allowable reimbursement for county clients.

Job Duties

• Reprice claims: Apply the most favorable applicable reimbursement using discounts, custom fee schedules, statutory limits (where applicable) and negotiated contract terms for MedHealth clients. When no negotiated rate exists, the Medical Claims Repricer/Analyst works with providers to negotiate the most favorable rates for MedHealth clients.
• Analyze codes: Review CPT, ICD-10, and HCPCS codes to confirm services are categorized correctly and priced using the appropriate reimbursement.
• Check errors: Identify and correct discrepancies in electronic or paper billing forms, including duplicate billing, patient information, incorrect codes, or other claim inaccuracies.
• Resolve issues: Correct pricing or other billing errors through correcting, repricing, documenting the resolution, and notifying the billing entity when adjustments are completed and ready to be paid.
• Track productivity: Monitor claim volume, processing timeliness, accuracy, appeal documentation, and approved-claim payment readiness.
• Negotiate provider rates: Communicate with hospitals, physician offices, and other billing entities to obtain favorable rates, clarify billed charges, and support resolution of disputed claims.
• Maintain compliance documentation: Record repricing decisions, supporting rate references, provider communications, and claim adjustments to support audit readiness and appeal review.
• Accounting Teamwork: Communicate with others in the process cycle to ensure that all are accurately processed, reviewed and paid timely. Assist as needed in clarifying or expediting issues.

Minimum Qualifications

• Education: High school diploma required; college degree preferred.
• Experience: 1 to 3 years of experience in medical billing, coding, repricing or insurance claims processing.
• Skills: Strong knowledge of medical terminology, basic math, and computer programs such as Microsoft Excel. Familiarity with CPT, ICD-10, and HCPCS codes is essential for success in this role because Medical Claims Repricer/Analyst ensure the accurate and timely processing of claims.
• Detail oriented: Maintain a high level of accuracy and efficiency to prevent payment errors and ensure claims are processed timely and correctly.
• Communication: Comfortable speaking with hospitals and physician offices to negotiate aggressive favorable rates and assisting in resolving occasional appeals.

This position is based in the Oklahoma City corporate office, Monday through Friday, from 8:00 a.m. to 5pm