Payment Integrity Specialist

Job Summary

To ensure accurate reimbursement and regulatory compliance, the remote Payment Integrity Specialist will monitor audits and refund requests, audit payments against payer contracts, and collaborate with cross-functional teams to identify discrepancies and optimize revenue integrity.

Key responsibilities

• Monitor internal and external audits related to claims, payments, and refunds
• Review and process refund requests from payers and patients while ensuring timely posting of payments
• Validate that payments align with negotiated payer contracts and Most Favored Nation (MFN) provisions

Required qualifications

• Bachelor's degree in healthcare administration, finance, or related field (or equivalent experience)
• 3-5 years of experience in medical billing, payment integrity, or payer contract auditing
• Strong understanding of MFN laws, payer policies, and healthcare reimbursement models
• Proficiency in claims management systems and data analytics tools
• CPCS or similar certification preferred