The Pricing Resolution Specialist analyzes inpatient medical claims, reviews documentation for reimbursement, and provides support on claims adjudication issues.
Position Summary
At MedReview, our mission is to bring accuracy, accountability, and clinical excellence to healthcare. As such, we are a leading authority in payment integrity solutions including DRG Validation, Cost Outlier, and Readmission reviews.
Pricing and analysis of inpatient medical claims utilizing NYCHSRO/MedReview and payer specific systems, adjudication platforms, policies, and procedures. Provide support to various departments related to claim status, claim adjudication questions, and any basic questions related to the adjudication of an inpatient medical claim.
Responsibilities:
This list does not represent all responsibilities for this position. Candidate must understand and be willing and able to assume roles and responsibilities other than these to meet the needs of MedReview Operations in general.
Qualifications:
At MedReview, our mission is to bring accuracy, accountability, and clinical excellence to healthcare. As such, we are a leading authority in payment integrity solutions including DRG Validation, Cost Outlier, and Readmission reviews.
Pricing and analysis of inpatient medical claims utilizing NYCHSRO/MedReview and payer specific systems, adjudication platforms, policies, and procedures. Provide support to various departments related to claim status, claim adjudication questions, and any basic questions related to the adjudication of an inpatient medical claim.
Responsibilities:
This list does not represent all responsibilities for this position. Candidate must understand and be willing and able to assume roles and responsibilities other than these to meet the needs of MedReview Operations in general.
- Responsible for reviewing data in the review application and client claim processing system, and comparing with corresponding UB, medical record or other documentation.
- Responsible for reviewing all necessary documentation as necessary to determine appropriate reimbursement for a claim.
- Responsible for reviewing adjudication software system’s claim and line items for determination of how to price a claim / line item.
- Possess ability to work at a computer for extended periods.
- Other duties as assigned.
Qualifications:
- High School Diploma or Equivalent
- Minimum of 5 years related work experience. Prior experience with claim adjudication systems, grouping and pricing software, and other claim adjudication and claim pricing systems.
- Basic knowledge of medical terminology.
- Good knowledge of Microsoft Word, Excel and Outlook
- Intermediate mathematics aptitude
- Basic communication skills
- Proficient organizational abilities
- Proficient comprehension capabilities
- Ability to prioritize multiple tasks
- Experience with UB/inpatient institutional claims
- Proficient knowledge of Medicare and Medicaid billing & payment and coverage guidelines
- Strong experience in the analysis and processing of claims, quality assurance, CMS payment methodologies (i.e., DRGs, Cost Outliers)
- Must be able to work with minimal supervision
- Creative thinker with good skills at problem resolution specifically related to healthcare claim adjudication
Similar Jobs
.png)
Cloud • Insurance • Payments • Software • Business Intelligence • App development • Big Data Analytics
Lead and manage an engineering team to deliver AI-based services, providing technical guidance, coaching, and ensuring quality and delivery goals.
Top Skills:
Ai EngineeringCloud Native ArchitectureConfluenceDevOpsJIRAScrum
Artificial Intelligence • Cloud • HR Tech • Information Technology • Productivity • Software • Automation
The Senior HRBP Manager will drive business results through talent initiatives, coach leaders on people management, and enhance organizational effectiveness using data analysis.
Top Skills:
AIData Analysis ToolsHr Systems
Artificial Intelligence • Cloud • HR Tech • Information Technology • Productivity • Software • Automation
The Global Client Director will lead executive relationship management with top accounts, achieve financial targets, and oversee the strategic integration of AI into client relations and solutions.
Top Skills:
AICustomer ServiceHrIt Operations ManagementIt Service ManagementSecurity Operations
What you need to know about the NYC Tech Scene
As the undisputed financial capital of the world, New York City is an epicenter of startup funding activity. The city has a thriving fintech scene and is a major player in verticals ranging from AI to biotech, cybersecurity and digital media. It also has universities like NYU, Columbia and Cornell Tech attracting students and researchers from across the globe, providing the ecosystem with a constant influx of world-class talent. And its East Coast location and three international airports make it a perfect spot for European companies establishing a foothold in the United States.
Key Facts About NYC Tech
- Number of Tech Workers: 549,200; 6% of overall workforce (2024 CompTIA survey)
- Major Tech Employers: Capgemini, Bloomberg, IBM, Spotify
- Key Industries: Artificial intelligence, Fintech
- Funding Landscape: $25.5 billion in venture capital funding in 2024 (Pitchbook)
- Notable Investors: Greycroft, Thrive Capital, Union Square Ventures, FirstMark Capital, Tiger Global Management, Tribeca Venture Partners, Insight Partners, Two Sigma Ventures
- Research Centers and Universities: Columbia University, New York University, Fordham University, CUNY, AI Now Institute, Flatiron Institute, C.N. Yang Institute for Theoretical Physics, NASA Space Radiation Laboratory
