Healthcare Claims Pricing Specialist

Job Summary

A company is looking for a Healthcare Claims Pricing & Payment Integrity Specialist.

Key Responsibilities

• Research and interpret CMS reimbursement rules, state payment guidelines, and fee schedules
• Translate payer and provider contract terms into pricing logic and audit approaches
• Develop and refine repricing methodologies used to identify potential overpayments

Required Qualifications

• Experience in healthcare claims repricing, reimbursement, payment integrity, or claims analytics
• Strong understanding of CMS reimbursement methodologies, state payment rules, and fee schedules
• Experience working directly with claims datasets in a production or operational environment
• Ability to research and interpret reimbursement guidance without fully defined requirements
• Ability to write complex SQL queries for data analysis and validation