Pricing Resolution Specialist II

MedReview is a leading provider of payment integrity solutions that help national and regional health plans promote population health, ensure payment accuracy, reduce administrative waste, improve provider relationships, and optimize financial performance. For more than four decades, MedReview has partnered with health plans, third-party administrators, and other healthcare organizations to deliver technology-enabled solutions that identify savings opportunities, drive operational efficiency, and improve healthcare outcomes.

MedReview is seeking a Pricing Resolution Specialist II to join our Payment Integrity Operations team. This role is responsible for the accurate review, analysis, and repricing of healthcare claims across multiple lines of business and reimbursement methodologies. The Pricing Resolution Specialist II applies CMS reimbursement policies, payer-provider contracts, client-specific requirements, and internal operational guidelines to ensure claims are processed accurately and consistently.

The ideal candidate will possess strong healthcare claims knowledge, reimbursement expertise, and analytical problem-solving skills. This role requires the ability to interpret complex claim data, contract language, pricing methodologies, and reimbursement policies while delivering timely, accurate, and well-supported pricing determinations.

• Review medical claims, claim forms, adjudication records, medical records, and supporting documentation to validate claim information and determine appropriate pricing actions.
• Apply CMS reimbursement methodologies, payer-provider contract terms, health plan requirements, and internal pricing guidelines to accurately calculate reimbursement.
• Analyze claim and line-level details for Medicare, Medicaid, and Commercial claims.
• Review inpatient, outpatient, professional, and institutional (UB) claims to ensure accurate pricing outcomes.
• Utilize claims pricing and adjudication systems to identify reimbursement opportunities and pricing discrepancies.

• Investigate claim status questions, pricing variances, reimbursement issues, and claim processing concerns.
• Research complex reimbursement scenarios using contract language, pricing methodologies, policies, and supporting documentation.
• Identify and resolve claim pricing discrepancies through established operational procedures and escalation pathways.
• Ensure pricing decisions are accurate, defensible, and compliant with applicable reimbursement standards.

• Clearly document pricing determinations, supporting rationale, and claim resolution activities.
• Maintain complete and accurate records to support audit readiness and operational transparency.
• Adhere to department productivity, quality, accuracy, and turnaround-time standards.
• Monitor work quality and ensure pricing outcomes are consistently aligned with organizational and client requirements.

• Partner with Operations, Client Services, and other internal teams to support claim resolution and reimbursement accuracy.
• Respond to internal inquiries regarding pricing decisions and claim disposition.
• Support special projects, workflow improvements, and operational initiatives as assigned.
• Participate in team meetings, training activities, and continuous improvement efforts.

• High school diploma or equivalent.
• Minimum of 2 years of healthcare claims, claim adjudication, reimbursement, pricing, payment integrity, or related experience.
• Experience using healthcare claims adjudication, pricing, grouping, or encoder systems such as Facets, Cosmos, CAS, PSI, Encoder, or similar platforms.
• Working knowledge of CMS reimbursement methodologies and Medicare, Medicaid, and Commercial reimbursement principles.
• Understanding of payer-provider contract language and reimbursement structures.
• Strong analytical, problem-solving, and critical-thinking skills.
• High attention to detail and accuracy.
• Strong written and verbal communication skills.
• Basic knowledge of medical terminology and HIPAA privacy requirements.
• Proficiency with Microsoft Office applications, including Outlook, Word, and Excel.
• Ability to work independently while managing multiple priorities and deadlines.

• Experience reviewing inpatient, outpatient, professional, and institutional (UB) claims.
• Experience in payment integrity, healthcare claims auditing, or healthcare reimbursement operations.
• Knowledge of healthcare contract interpretation and reimbursement analysis.
• Experience working with health plans, third-party administrators, or healthcare payment integrity organizations.

• High-speed internet connection (300 Mbps recommended).
• Secure and dedicated workspace with minimal distractions.
• Ability to maintain the confidentiality of PHI and comply with HIPAA requirements.
• Ability to sit and work at a computer for extended periods of time.
• Ability to utilize multiple systems and applications simultaneously throughout the workday.

Within the first 12 to 24 months, this individual will:

• Consistently meet or exceed departmental quality, productivity, and turnaround expectations.
• Demonstrate expertise in healthcare reimbursement methodologies and claims pricing practices.
• Accurately resolve pricing discrepancies and reimbursement issues across multiple claim types.
• Deliver clear, well-supported pricing determinations that withstand audit and client review.
• Build strong working relationships with internal operational and client-facing teams.
• Contribute to operational improvements that enhance pricing accuracy, efficiency, and client satisfaction.
• Support MedReview's commitment to payment accuracy and healthcare cost containment.

• Full-time position.
• Remote or office-based depending on operational needs.
• Flexible scheduling may be available based on business requirements.
• Participation in periodic late-shift rotations may be required.
• Daily work involves intensive computer usage, claims analysis, system navigation, and electronic communication.