Pricing Resolution Processor II

MedReview; United States; Remote; USD 37,000 - 41,000; Full time

Job summary

MedReview is seeking a Pricing Resolution Processor II for its Remote Operations team. The role focuses on reviewing, grouping, and pricing healthcare facility claims to ensure reimbursement accuracy and detect potential overpayments.

The candidate will apply client-specific methodologies, regulatory guidance, and internal standards while maintaining productivity and quality in a high-volume environment. Strong attention to PHI, HIPAA compliance, and data quality is essential.

Qualifications

• Must have high school diploma or equivalent and 1–3 years in healthcare claims processing.
• Strong knowledge of ICD-10 coding, CPT coding, and revenue codes.
• Excellent analytical, problem solving, and data validation skills.
• Ability to learn multiple systems and maintain data accuracy.
• Excellent written and verbal communication abilities.

Responsibilities

• Review claims for completeness, accuracy, and eligibility.
• Validate information before pricing activity begins.
• Group facility claims according to client/internal methodologies.
• Apply payer specific reimbursement methodologies and contractual terms.
• Identify pricing discrepancies and resolve issues promptly.
• Maintain documentation supporting pricing decisions and processing activities.
• Support process improvement and collaboration across teams.

Skills

Analytical skills

Attention to detail

Microsoft Excel

Communication skills

Independent work

Time management

Education

High school diploma or equivalent

Healthcare claims processing knowledge

ICD-10/CPT coding knowledge

PHI/HIPAA awareness

Tools

Microsoft Office Suite

Claims processing systems

Job description

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.

The Opportunity

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.

Qualifications

Required 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

• Comprehensive Medical, Dental, and Vision Coverage


• 401(k) with Employer Match


• Generous Paid Time Off and Paid Holidays


• Flexible Spending Accounts (FSA) and Commuter Benefits


• Professional Development and Continuing Education Opportunities


• LinkedIn Learning Access and Ongoing Training Programs


• Employee Wellness Programs


• Collaborative and Mission‑Driven Work Environment