Claims Payment Integrity Specialist, Health Plan

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🔥 2 minutes ago

🗿 South Dakota, Wisconsin – Remote

🗿 South Dakota – Remote 🧀 Wisconsin – Remote

💵 $21 - $34 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

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Sanford Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1894

🛡️ Insurance

🏥 Healthcare

⚕️ Healthcare Insurance

Insurance • Healthcare • Healthcare Insurance

Sanford Health is the largest rural health system in the United States, dedicated to transforming the healthcare experience and providing access to world-class healthcare in America's heartland. Headquartered in Sioux Falls, South Dakota, Sanford Health serves over 1. 4 million patients and nearly 200,000 health plan members across 250,000 square miles. The integrated health system includes 48 medical centers, 211 clinic locations, and more than 160 senior living centers, employing 2,900 physicians and advanced practice providers. Sanford Health is committed to offering compassionate care through its Centers of Excellence, focusing on specialties such as cancer, orthopedics, women’s health, and genetics. Additionally, it provides affordable health insurance, engages in extensive clinical trials, and supports personalized genetic medicine.

📋 Description

• 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

• 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

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