Payment Integrity Specialist
Core
Ensures accuracy and compliance of claims and payments in Cityblock's value-based arrangements by identifying discrepancies, analyzing root causes, and driving recoveries.
Role type
Payment Integrity Specialist (Healthcare Claims & Reimbursement)
Builds
Accurate payment flows and compliant reimbursement processes for Medicaid, Medicare Advantage, and Dually Eligible populations.
Domain
Healthcare Payer / Managed Care / Value-Based Care
Deliverable
production ML models | product features | dashboards & analysis | client delivery
Required skills
Claims auditing, CMS and Medicaid reimbursement rules, CPT/HCPCS/ICD-10/DRG coding, data analysis (Excel, SQL), root-cause analysis, fraud/waste/abuse detection
Preferred skills
Value-based/capitation arrangements, Medicaid experience, CPC/CFE/AHFI certification
Technologies
Excel, SQL
Responsibilities
Review claims against contract terms and coding standards; identify overpayments, underpayments, and improper payments; reconcile expected vs. actual reimbursement; define and validate payment-integrity edits and rules; analyze claims data to quantify financial impact; build reports and dashboards tracking recovery outcomes.
Seniority
Mid-level, hands-on IC
