Pricing Resolution Processor II

MedReview Inc.

New York (NY)

Remote

USD 37,000 - 41,000

Full time

6 days ago

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Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

401(k) matching

Paid time off

Paid holidays

FSA and commuter benefits

Professional development

Job summary

MedReview Inc. is seeking a Pricing Resolution Processor II to join the Payment Integrity Operations team. This remote role focuses on reviewing, grouping, and pricing facility claims to identify overpayments and ensure reimbursement accuracy in a high-volume environment.

The ideal candidate has healthcare claims processing experience, strong analytical skills, and attention to detail. Candidates must maintain a secure PHI/HIPAA-compliant workspace.

Qualifications

High school diploma or equivalent.
1–3 years experience in healthcare claims processing or related field.
Knowledge of ICD-10 diagnosis coding, CPT coding, Revenue Codes, medical terminology.
Strong analytical and problem-solving skills.
Ability to learn and navigate multiple systems.
Excellent written and verbal communication.
Proficiency with Outlook, Excel, and Word.
Ability to manage high-volume workload with quality.

Responsibilities

Review assigned healthcare claims for completeness, accuracy, and eligibility for review.
Validate claim information and supporting documentation before pricing activities begin.
Group facility claims using client/internal systems according to methodologies.
Apply client-required reimbursement methodologies.
Identify pricing discrepancies and potential overpayments.

Skills

Attention to detail

Analytical skills

Communication skills

Time management

Independent work

ICD-10/CPT knowledge

Microsoft Office

Education

High school diploma

Associate degree preferred

Tools

Microsoft Office

Job description

The Opportunity

About MedReview

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 Processor II to join our Payment Integrity Operations team. This role is responsible for reviewing, grouping, and pricing routine healthcare facility claims to identify potential overpayments and ensure reimbursement accuracy. The Pricing Resolution Processor II applies client-specific reimbursement methodologies, payer requirements, regulatory guidelines, and internal operational standards to support accurate and timely claim pricing decisions.

The ideal candidate will possess healthcare claims processing experience, strong analytical skills, and a high level of attention to detail. This position requires the ability to evaluate claim information, identify discrepancies, validate data accuracy, and ensure compliance with reimbursement policies and contractual obligations while maintaining productivity and quality standards in a high-volume environment.

This position is remote. Candidates must maintain a secure workspace that protects protected health information (PHI) and HIPAA-regulated data.

Key Responsibilities

Claims Review and Validation

Review assigned healthcare claims for completeness, accuracy, and eligibility for review
Validate claim information and supporting documentation before pricing activities begin
Analyze claim details to ensure all required information has been submitted and appropriately documented
Identify missing, inaccurate, or inconsistent claim data and initiate appropriate resolution steps
Maintain high levels of accuracy while managing assigned workloads and turnaround expectations

Claim Grouping and Pricing

Group facility claims using client and internal systems in accordance with established methodologies
Apply reimbursement methodologies based on client requirements, regulatory guidance, and contractual obligations
Ensure claims are priced accurately and consistently according to payer-specific guidelines
Review claim information to identify potential overpayments and reimbursement discrepancies
Utilize internal applications and client platforms to support pricing and claim review activities

Compliance and Quality Assurance

Ensure adherence to payer contract requirements, regulatory standards, and internal operational procedures
Validate data entry and pricing calculations to maintain pricing accuracy
Monitor claim outcomes to identify and resolve pricing discrepancies in a timely manner
Maintain complete and accurate documentation supporting pricing determinations and claim processing activities
Meet departmental productivity, quality, accuracy, and turnaround-time expectations

Operational Support and Collaboration

Escalate complex claim issues, discrepancies, or reimbursement concerns when appropriate
Demonstrate sound judgment when evaluating claims and determining when management review is necessary
Collaborate with internal operational teams to support claim pricing accuracy and workflow efficiency
Participate in process improvement initiatives, training programs, and departmental meetings
Support additional duties and special projects as assigned to meet operational and organizational needs

QualificationsRequired Qualifications

High school diploma or equivalent
Minimum of 1-3 years of experience in healthcare claims processing, healthcare billing, reimbursement, revenue cycle, or related healthcare operations
Working knowledge of ICD-10 diagnosis coding, CPT coding, Revenue Codes, medical terminology, and the healthcare claims adjudication process
Strong analytical and problem-solving skills with the ability to make sound decisions based on available claim information
Ability to learn and navigate multiple systems and applications simultaneously
Excellent written and verbal communication skills
Strong organizational skills with the ability to prioritize work effectively and manage competing deadlines
High attention to detail and commitment to data accuracy
Proficiency with Microsoft Office applications, including Outlook, Excel, and Word
Ability to manage a high-volume workload while maintaining quality and productivity standards
Ability to work independently with minimal supervision
Ability to remain calm and professional in a fast-paced environment with frequent interruptions

Preferred Qualifications

Associate degree in Healthcare Administration, Business Administration, Health Information Management, or a related field
Experience with healthcare payment integrity operations
Experience reviewing and pricing facility claims
Familiarity with payer reimbursement methodologies and provider contract language
Experience working with health plans, third-party administrators, or healthcare payment integrity organizations
Knowledge of Medicare, Medicaid, and Commercial healthcare reimbursement principles

What Success Looks Like

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

Consistently meet or exceed departmental productivity, quality, and turnaround-time expectations
Demonstrate proficiency in claim grouping methodologies and reimbursement pricing standards
Accurately identify pricing discrepancies and reimbursement opportunities
Deliver timely and accurate pricing determinations with minimal rework
Effectively navigate multiple client and internal systems while maintaining efficiency
Build strong working relationships with operational and cross-functional teams
Contribute to process improvements that enhance operational effectiveness and pricing accuracy
Support MedReview's commitment to payment accuracy, client satisfaction, and healthcare cost containment

Remote Work Requirements

High-speed internet connection (100 Mbps per person recommended) with secure Wi-Fi access
Secure and dedicated workspace with minimal interruptions
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

Work Environment

Full-time position
Remote or office-based depending on operational needs
Fast-paced, production-oriented healthcare operations environment
Daily work involves extensive computer use, claims review, data validation, pricing analysis, and electronic communication
Position requires strong focus, attention to detail, and the ability to manage multiple priorities simultaneously

Compensation

Pay Range: $27.00 - $30.00 per hour, commensurate with experience.

Benefits