Solution Specialist, Payment Intelligence

Summary

AArete is a global management and technology consulting firm. The Solution Specialist, Payment Intelligence will deliver claims analytics and post-pay data mining edits for client engagements, serving as a subject matter expert on claims payment strategies. The role also supports remediation, process improvement, automation, regulatory research, and client-ready deliverables.

Responsibilities

• Support the development, identification and analysis of payment accuracy opportunities through remediation
• Utilize analytics to identify claims payment opportunities through your knowledge of standard payment methodologies including Prospective Payment Systems (IPPS/OPPS), fee for service, Groupers, RUG, etc
• Support process improvements and automation initiatives
• Conduct research on current events, changes in regulatory requirements and market trends impacting health plan reimbursement
• Contribute to the preparation of client ready deliverables with clear and actionable insight
• Exercise sound judgement and clear and direct communication in all aspects of your work
• Other duties as assigned

Skills

• 2+ years of experience in payment integrity, healthcare analytics, or payer operations
• Foundational knowledge of claims processing across multiple lines of business, including Medicare, Medicaid, ACA/Marketplace, Commercial, and Duals
• Experience across various spend areas (professional, ancillary, outpatient, and inpatient), familiarity with modifiers, place of service codes, and NPI/TIN relationships
• Ability to identify incorrect claims payments
• Knowledge of industry vendors and tools related to claims processing, provider data, and contract management
• Understanding of end-to-end claims processes, including claims management, provider lifecycle, and network optimization
• Strong professional communication skills, including written, verbal, interpersonal, and in-person presentation expertise
• Advanced proficiency utilizing Microsoft Excel
• Strong analytical, data interpretation, and problem-solving skills
• Ability to identify client savings opportunities and develop actionable business cases
• Strong working knowledge of managed care claims coding (Current Procedural Terminology (CPT), International Classification of Diseases (ICD), Healthcare Common Procedure Coding System (HCPCS), Revenue Codes), and federal/state Medicaid payment rules
• Bachelor's Degree or additional years of experience in lieu of degree
• Must be legally authorized to work in the United States without the need for employer sponsorship
• Policy & Claims Editing Expertise
• Research and interpretation of healthcare policies and regulations
• Experience in reimbursement policy writing and claims editing
• Proficiency in data mining to detect errors and inconsistencies
• Ability to crosswalk and compare edits and policies
• Knowledge of claims editing processes, including Prepay/Post-Pay, COB, Subrogation, Fraud Detection, and Medical Record Reviews
• Contract Configuration & Provider Data Expertise
• Interpretation of provider contract terms and pricing methodologies, including fee schedules, per diem, DRGs, cost-plus, and outlier payments
• Understanding of contract carve-outs, including bundled services, readmissions, and reductions
• Experience in contract pricing and claims reimbursement analysis
• Ability to price and reprice claims based on contractual agreements
• Understanding of provider TIN and NPI relationships
• Familiarity with network processes, including Optimization, Adequacy, and Pricing
• Familiarity with claims adjudication systems (e.g., Facets, QNXT, Amisys, etc.)
• Experience with SQL or other query languages
• Experience in reimbursement policy
• Knowledge of COB, Subrogation, Fraud Detection, and Medical Record Reviews
• Experience with financial impact modeling, savings forecasting, and ROI analysis
• Exposure to AI/ML models for aberrant billing pattern detection
• Understanding of EDI formats (837/835) and how errors propagate through the claim lifecycle
• Familiarity with industry vendors
• Based in Chicago, IL, and flexible to work from our Chicago office as needed

Qualifications

Must Haves

• 2+ years of experience in payment integrity, healthcare analytics, or payer operations
• Foundational knowledge of claims processing across multiple lines of business, including Medicare, Medicaid, ACA/Marketplace, Commercial, and Duals
• Experience across various spend areas (professional, ancillary, outpatient, and inpatient), familiarity with modifiers, place of service codes, and NPI/TIN relationships
• Ability to identify incorrect claims payments
• Knowledge of industry vendors and tools related to claims processing, provider data, and contract management
• Understanding of end-to-end claims processes, including claims management, provider lifecycle, and network optimization
• Strong professional communication skills, including written, verbal, interpersonal, and in-person presentation expertise
• Advanced proficiency utilizing Microsoft Excel
• Strong analytical, data interpretation, and problem-solving skills
• Ability to identify client savings opportunities and develop actionable business cases
• Strong working knowledge of managed care claims coding (Current Procedural Terminology (CPT), International Classification of Diseases (ICD), Healthcare Common Procedure Coding System (HCPCS), Revenue Codes), and federal/state Medicaid payment rules
• Bachelor's Degree or additional years of experience in lieu of degree
• Must be legally authorized to work in the United States without the need for employer sponsorship

Nice to Haves

• Policy & Claims Editing Expertise
• Research and interpretation of healthcare policies and regulations
• Experience in reimbursement policy writing and claims editing
• Proficiency in data mining to detect errors and inconsistencies
• Ability to crosswalk and compare edits and policies
• Knowledge of claims editing processes, including Prepay/Post-Pay, COB, Subrogation, Fraud Detection, and Medical Record Reviews
• Contract Configuration & Provider Data Expertise
• Interpretation of provider contract terms and pricing methodologies, including fee schedules, per diem, DRGs, cost-plus, and outlier payments
• Understanding of contract carve-outs, including bundled services, readmissions, and reductions
• Experience in contract pricing and claims reimbursement analysis
• Ability to price and reprice claims based on contractual agreements
• Understanding of provider TIN and NPI relationships
• Familiarity with network processes, including Optimization, Adequacy, and Pricing
• Familiarity with claims adjudication systems (e.g., Facets, QNXT, Amisys, etc.)
• Experience with SQL or other query languages
• Experience in reimbursement policy
• Knowledge of COB, Subrogation, Fraud Detection, and Medical Record Reviews
• Experience with financial impact modeling, savings forecasting, and ROI analysis
• Exposure to AI/ML models for aberrant billing pattern detection
• Understanding of EDI formats (837/835) and how errors propagate through the claim lifecycle
• Familiarity with industry vendors
• Based in Chicago, IL, and flexible to work from our Chicago office as needed

Benefits

• Flexible PTO, monthly half-day refuels, volunteer time off, 10 paid holidays
• Own Your Day flexible work policy
• Competitive majority employer-paid benefits: Medical, Dental, Vision, 401K Match
• Generous paid parental leave options
• Employer paid Life Insurance, STD, LTD
• Charitable contribution matching program
• New client commission opportunities and referral bonus program
• Bike share discount program