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Claims Payment Integrity Specialist, Health Plan
Sanford Health. Conduct pre- or post-payment claim reviews to identify overpayments, underpayments, duplicate payments, coding errors, and contractual discrepancies .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in claims analysis, payment integrity, and regulatory compliance within healthcare operations. Proficient in utilizing data analytics and reporting tools to identify payment discrepancies and implement corrective actions.
Highest-signal resume keywords
Claims AnalysisPayment IntegrityRegulatory ComplianceData AnalyticsHealthcare Operations
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
Claims ProcessingReimbursement MethodologiesAudit MethodologiesProvider Contract InterpretationFee Schedule AnalysisMedical Policy UnderstandingPayment Model KnowledgeRecovery ActionsTrend AnalysisAnomaly Detection
Soft Skills
Written CommunicationCollaborationProblem-SolvingAttention to DetailAnalytical Thinking
Tools & Technologies
Claims SystemsMicrosoft ExcelMicrosoft WordMicrosoft OutlookReporting Tools
Certifications & Qualifications
Certified Professional Coder (CPC)Certified Payment Integrity Professional (CPIP)
Industry Keywords
CMSMedicaidMedicareCommercialExchangeTPAProgram IntegrityAuditHealthcare AdministrationPayment Discrepancies
About the role
Key responsibilities & impact- Conduct pre- or post-payment claim reviews to identify overpayments, underpayments, duplicate payments, coding errors, and contractual discrepancies
- Analyze claims using data analytics, reporting tools, and audit methodologies to detect trends, anomalies, and potential payment risks
- Lead implementation of initiatives addressing incorrect payment trends or new claim editing solutions
- Validate claims compliance with CMS, state Medicaid agencies, ACA, ERISA, and applicable regulatory requirements
- Interpret benefits, provider contracts, fee schedules, reimbursement methodologies, and medical policies
- Initiate recovery actions for identified overpayments with providers, recovery vendors, or internal adjustment processes
- Prepare written communications detailing audit findings and recovery rationales
- Support appeals, disputes, and provider inquiries related to payment integrity findings
- Partner with Claims Operations, Provider Relations, Compliance, Legal, Configuration, and Finance to resolve root causes of payment errors
- Provide recommendations to improve claims configuration, policies, workflows, corrective actions, and preventive controls
- Develop strategies to maximize medical cost savings and administrative savings while minimizing over- and underpayment errors
- Maintain documentation of audit activities, findings, and outcomes
- Report on payment integrity performance, recoveries, and identified risk areas
- Participate in special projects, regulatory audits, and program integrity initiatives
Requirements
What you’ll need- Associate's degree in Healthcare Administration, Business, Finance or a related field, required
- Bachelor's degree preferred
- Equivalent years of relevant work experience or combination of higher education and relevant experience may be considered in lieu of degree completion
- Two (2) years of experience in claims, payment integrity, audit, program integrity, or healthcare operations required
- Experience working with multiple lines of business (Medicare, Medicaid, Commercial, Exchange, and/or TPA) required
- Proficiency with claims systems and Microsoft Office tools, including Excel, Word, and Outlook, required
- Experience with claims data analytics or recovery vendor management preferred
- Knowledge of CMS and state Medicaid program integrity expectations preferred
- Strong understanding of healthcare claims processing, reimbursement methodologies, and benefit structures
- Working knowledge of Medicare, Medicaid, commercial, exchange, and TPA payment models
- Ability to interpret provider contracts, fee schedules, and medical policies
- Certified Professional Coder (CPC), Certified Payment Integrity Professional (CPIP), or similar certification preferred