Payment Integrity & Claims Systems Strategist (Healthcare Payor)
Job Number: NR61600047
Job Description
Payment Integrity & Claims Systems Strategist (Healthcare Payor)
Location: On-Site, Pittsburgh, PA 15219 (some hybrid flexibility, after training)
Hours: Daylight Schedule
Status: Full-Time/Permanent - Direct Hire as an employee of the Company with access to full benefits
New Hire Starting Pay: Up to $81,000 annually (Based on experience)
After-Hire Earning Potential: Your compensation grows as you do. The Company offers incremental, performance-based pay increases tied to job experience and technical proficiency. While initial offers are based on current experience, successful team members have the opportunity to reach an earning ceiling of $118,000 annually through the internal advancement structure.
Company: Confidential – Leading Healthcare Payor
Mandatory Qualifications & Requirements
Candidates who do not meet these specific criteria will not be considered:
- Education & Experience: Bachelor’s degree with 4 years of relevant experience OR an equivalent combination of education and professional work experience specifically within healthcare payor/claims payment processing.
- Technical Proficiency: Professional-level experience using SQL for data extraction and Excel for advanced data analysis and senior-level reporting.
- Data Visualization: Demonstrated experience building dashboards and actionable insights using Power BI or Tableau.
- Claims Expertise: Proven ability to interpret professional and facility claim forms and a solid understanding of end-to-end claims workflows.
- Coding Knowledge: Ability to interpret and apply industry-standard claim edit rules, clinical coding guidelines, and regulatory references.
About the Role
In this critical role, you will shape how healthcare claims are processed and paid. As the subject matter expert for payment accuracy and claim editing, you will serve as the bridge between clinical policy and financial execution. This is an opportunity to drive payment integrity and compliance while collaborating with cross-functional teams to impact the organization's bottom line.
Primary Responsibilities
- Systems Management: Act as the primary expert for claim editing software; collaborate with external vendors and internal IT teams to implement and maintain industry-standard clinical coding edits.
- Data-Driven Strategy: Transform raw data into strategic decisions. Utilize SQL and BI tools to monitor edit performance, identify cost-saving opportunities, and ensure compliance with Medicare, Medicaid, and other payor requirements.
- Cross-Functional Leadership: Partner with Claims Operations, Medical Policy, and IT to align system edits with evolving clinical and financial goals.
- Compliance & Policy Oversight: Advise leadership on coding changes (AMA, CMS, NCCI) and regulatory updates. Ensure all system edits function as intended and adhere to strict compliance standards.
- Audit & Root Cause Analysis: Perform comprehensive audits of claims processes, identify root causes for payment inaccuracies, and recommend systemic solutions.
Preferred Skills & Certifications
- Coding Certification: Current Certified Coder (CCS, CCS-P, or CPC) or Registered Health Information Professional (RHIA/RHIT) is highly preferred.
- Database Knowledge: Familiarity with relational databases (e.g., Microsoft Access) beyond standard SQL querying.
- Project Management: A proactive mindset with the ability to lead impactful projects that adapt to changes in medical policy.
- Communication: High-level verbal and written communication skills for presenting complex data findings to senior management.
Working Conditions
- Hybrid Schedule: This role is primarily remote but requires mandatory in-office presence, as needed by the department.
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