Payment Integrity Professional

Job description

**This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Payment Integrity Professional based in the United States.** This is a remote opportunity for a payment integrity professional focused on improving claim accuracy and reducing unnecessary healthcare costs. You will use advanced medical coding knowledge, claims research, and data analysis to identify and validate opportunities for more accurate claim processing. The role combines independent decision-making with close collaboration across internal teams and external coding partners. You will work extensively with Medicare and Medicaid requirements, coding standards, and industry benchmarks. Your insights will help strengthen code-editing processes and support efficient, compliant claims operations. The position offers exposure to process improvement, project leadership, and strategic operational initiatives. It is well suited to a detail-oriented, analytical professional who can communicate complex coding concepts with confidence. ### Accountabilities - Research claims, coding guidelines, and data anomalies to identify opportunities that can improve payment accuracy and reduce unnecessary costs. - Apply advanced knowledge of CPT, HCPCS, ICD, Medicare, Medicaid, and correct-coding requirements to validate and develop new code-edit opportunities. - Conduct in-depth analysis and independently determine appropriate courses of action, including in situations involving ambiguity or complex coding considerations. - Collaborate with Code Edit Management, internal stakeholders, and external code-editing vendors to support effective processes and successful day-to-day operations. - Identify opportunities for process improvement and contribute to initiatives that enhance the accuracy, efficiency, and consistency of payment integrity activities. - Support projects and processes, potentially taking a leadership role in implementation, coordination, and continuous improvement efforts. - Present findings, recommendations, and coding-related information to internal audiences and larger groups as needed. - Maintain awareness of Medicare and Medicaid requirements, national benchmarks, industry standards, and evolving coding practices. - Follow established procedures while using sound judgment, analytical thinking, and minimal supervision to resolve issues and advance business objectives. - Work a standard schedule of 40 hours per week, Monday through Friday, with occasional travel for training or meetings. ## Requirements - Active Certified Professional Coder (CPC) certification through either AHIMA or AAPC is required. - At least 2 years of experience applying coding guidelines and submitting, reading, and/or interpreting healthcare claims. - Distinguished knowledge of American Medical Association CPT, HCPCS, and ICD code sets and their practical application. - Strong understanding of Centers for Medicare & Medicaid Services (CMS) requirements, state Medicaid guidelines, correct-coding initiatives, national benchmarks, and industry standards. - Experience with code-editing vendor tools is preferred, along with familiarity with payment integrity or code-editing processes. - Experience leading projects or operational processes is preferred. - Strong analytical thinking, attention to detail, problem-solving ability, and sound independent judgment. - Ability to work effectively in a fast-paced, metric-driven environment while managing priorities with limited direction. - Strong interpersonal and communication skills, including the confidence to present information to large audiences. - Proficiency with Microsoft Office applications; experience with Access or healthcare-specific systems is a plus. - Ability to maintain a positive, collaborative mindset and build productive relationships with diverse stakeholders. - Ability to work remotely from a dedicated, interruption-free workspace that protects confidential health information and meets applicable HIPAA requirements. - Reliable home internet is required, with at least 25 Mbps download and 10 Mbps upload speeds recommended/required for effective remote work. - Occasional travel to office locations for training or meetings may be required. ## Benefits - Annual base salary of **$65,000–$88,600**, depending on location, skills, experience, education, certifications, and other job-related factors. - Eligibility for a **bonus incentive plan** based on company and/or individual performance. - Remote, work-from-home position with a standard 40-hour workweek. - Medical, dental, and vision coverage. - 401(k) retirement savings plan. - Paid time off, company and personal holidays. - Paid parental and caregiver leave. - Short-term and long-term disability coverage. - Life insurance. - Additional programs and resources supporting employee wellness and whole-person well-being. - In certain states, eligible home-based employees may receive a bi-weekly contribution toward internet expenses. - Employer-provided telephone equipment appropriate to business requirements.