Payment Integrity Specialist
Location
United States
Posted
1 day ago
Salary
$70K - $86K / year
Seniority
Senior
Job Description
Payment Integrity Specialist
GeneDx
• Monitor internal and external audits related to claims, payments, and refunds • Conduct periodic audits of payer contracts and payment activity to ensure compliance with MFN laws and contractual terms • Identify and escalate discrepancies in payment rates, coding, and authorization processes • Review and process refund requests from payers and patients • Ensure timely and accurate posting of payments and resolution of denials • Maintain detailed records of transactions and audit findings • Validate that payments align with negotiated payer contracts and MFN provisions • Collaborate with legal and contracting teams to interpret and apply MFN rules • Support payer configuration reviews and contract audits • Stay current on federal and state regulations impacting payment integrity, including MFN laws • Ensure audit processes and documentation meet compliance standards • Assist in preparing responses to regulatory inquiries and payer audits • Partner with appeals, credentialing, and market access teams to resolve payment issues • Provide feedback and process improvement recommendations to operational teams • Participate in payer meetings and internal workgroups to enhance audit and payment workflows
Job Requirements
- 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
- Exceptional attention to detail, analytical thinking, and problem-solving skills
- Excellent communication and documentation abilities
- CPCS or similar certification preferred
Benefits
- Competitive compensation and benefits
- Health insurance
- Paid time off
- Flexible work arrangements
- Professional development opportunities
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