Payment Integrity Specialist

Summary  

 The Payment Integrity Specialist plays a critical role in ensuring accurate reimbursement and regulatory compliance across payer relationships. This position is responsible for monitoring audits and refund requests, auditing payments against payer contracts, and ensuring adherence to Most Favored Nation (MFN) laws. The specialist will collaborate cross-functionally with billing, appeals, finance, and compliance teams to identify discrepancies, mitigate risks, and optimize revenue integrity. 

Job Responsibilities 

Audit Oversight 

• 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. 

Refund and Payment Reconciliation 

• 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. 

Contract Compliance 

• 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. 

Regulatory Adherence 

• 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. 

Cross-Functional Collaboration 

• 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. 

Education, Experience, and Skills 

• 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. 
  
  

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