Pricing Resolution Specialist

TL;DR

Pricing Resolution Specialist (Healthcare Claims): Pricing and analysis of inpatient medical claims utilizing adjudication platforms, payer policies, and procedures with an accent on determining appropriate reimbursement and resolving claim adjudication issues. Focus on reviewing documentation, comparing data across systems, and applying CMS payment methodologies like DRGs and Cost Outliers.

Salary: $26.50–$30.00 per hour

Company

Leading authority in payment integrity solutions including DRG Validation, Cost Outlier, and Readmission reviews.

What you will do

• Review data in review applications and client claim processing systems, comparing with UB forms, medical records, or other documentation.
• Examine all necessary documentation to determine appropriate reimbursement for claims.
• Analyze adjudication software for claim and line items to price claims accurately.
• Provide support on claim status, adjudication questions, and basic inpatient claim issues.
• Work at a computer for extended periods and handle other duties as assigned.

Requirements

• High School Diploma or equivalent.
• Minimum 5 years related work experience with claim adjudication systems, grouping, pricing software, UB/inpatient institutional claims.
• Proficient knowledge of Medicare and Medicaid billing, payment, coverage guidelines, CMS methodologies (DRGs, Cost Outliers).
• Basic knowledge of medical terminology; intermediate math aptitude.
• Good knowledge of Microsoft Word, Excel, Outlook; strong organizational, communication, comprehension, prioritization skills.
• Ability to work with minimal supervision; creative problem-solving in healthcare claim adjudication.