Payment Integrity Specialist

Payment Integrity Specialist

Summary

The Payment Integrity Specialist plays a critical role in ensuring accurate reimbursement and regulatory compliance across payer relationships. This position is responsible for monitoring audits and refund requests, auditing payments against payer contracts, and ensuring adherence to Most Favored Nation (MFN) laws. The specialist will collaborate cross-functionally with billing, appeals, finance, and compliance teams to identify discrepancies, mitigate risks, and optimize revenue integrity.

Job Responsibilities

Audit Oversight

• Monitor internal and external audits related to claims, payments, and refunds.
• Conduct periodic audits of payer contracts and payment activity to ensure compliance with MFN laws and contractual terms.
• Identify and escalate discrepancies in payment rates, coding, and authorization processes.

Refund and Payment Reconciliation

Contract Compliance

Regulatory Adherence

Cross-Functional Collaboration

Education, Experience, and Skills

Physical Demands

This is a sedentary role requiring prolonged periods of sitting while working at a computer. Physical demands include :

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position.

Work Environment

This is a fully remote position. The employee will work from a home office or other suitable remote location with reliable high-speed internet access. Work is performed in a climate-controlled environment using standard office equipment including computer, phone, and video conferencing tools. Your standard work schedule and hours will be established in collaboration with your leader and may be adjusted to align with evolving business needs.

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