Claims Repricing Specialist

The Claims Repricing Specialist is responsible for the accurate repricing of medical claims with PPO contracts, fee schedules, Medicare-based methodologies, and alternative reimbursement arrangements. This role ensures that billed charges are translated into correct allowed amounts prior to claims adjudication and payment.

The Claims Repricing Specialist serves as a subject matter expert on reimbursement logic, contract interpretation, and pricing configuration, partnering with Claims Operations, Strategic Network Partners/ Provider Relations, Engineering and Product Development to ensure payment accuracy, regulatory compliance and provider satisfaction.

What you'll do:

• Reprice professional, facility, and ancillary claims using:
  • PPO Fee Schedules
  • DRG/ APC methodologies
  • Percent of charges contracts
  • Per Diem or case rates
  • Medicare-based and RBRVS logic
  • Other proprietary methodologies as appropriate
• Validate line-level and claim level allowed amounts prior to adjudication
• Ensure correct application of:
  • Modifiers
  • Carve-out or exclusions
  • Implant or high-cost service logic (stop loss components)
• Interpret provider contracts and reimbursement exhibits to determine pricing intent.
• Translate contract language into repricing configuration and business rules.
• Identify and report conflicts between contract terms and system logic; recommend resolutions.
• Configure and maintain contract loading tables and crosswalks.
• Perform testing and validation of pricing changes in coordination with external pricing vendors and internal departments such as Claims Operations, Engineering or Product Development.
• Investigate repricing discrepancies and claim edits.
• Resolve escalated claims involving:
• Multi-contract scenarios
  • Out-of-network exceptions
  • Coordination of Benefits
  • High dollar or complex facility claims
  • Transplant claims
• Collaborate with internal and external partners to resolve payment disputes and appeals related to contract terms.
• Assist with implementation of new products, new networks and vendors.
• Collaborate with external vendors and internal cross functional departments to report and resolve issues or provide continuous process improvement recommendations.
• Provide guidance and training to claims processors or other internal departments on pricing methodologies.

To be successful in this role, you'll need:

• High School diploma required; Bachelors degree in Healthcare, Business, Finance or related field preferred.
• 3-5 years experience in healthcare claims, repricing or payment integrity in a Third Party or Health insurance payer setting.
• Demonstrated knowledge of
  • CPT/ HCPCs coding
  • Revenue/ Procedure codes
  • DRG/ APC structures
  • PPO reimbursement methodologies
• Proficiency with repricing tools, healthcare payor repricing portals, and fee schedule maintenance.

Nice to have

• Reference-based pricing (RBP), dialysis/ specialty pricing and transplant pricing experience preferred.
• Provider appeals background preferred.
• Experience with claims adjudication platforms preferred but not required.
• Knowledge of Google suite of office applications such as Gmail, Google Docs, Slides, Sheets preferred but not required.

Pay Transparency Statement 

This is a hybrid position based out of our Lehi office, with the expectation of being in office at least two weekdays per week. #LI-hybrid

The actual pay rate offered within the range will depend on factors including geographic location, qualifications, experience, and internal equity. In addition to the hourly rate, you will be eligible for 10,000 stock options and benefits like health insurance, 401k, and paid time off. Learn more about our benefits at https://jobs.collectivehealth.com/benefits/.