Payment Integrity Recovery Specialist I

POSITION SUMMARY 

The Payment Integrity Recovery Specialist I is responsible for identifying, auditing, and recovering claims overpayments. This role partners with internal stakeholders, providers, and external vendors to ensure accurate claims payment and compliance with contractual, federal, and state requirements. The specialist performs detailed research and analysis, facilitates recoveries, and supports resolution of complex overpayment issues while maintaining strong provider relationships.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job, an individual must perform each essential function satisfactorily, with or without reasonable accommodation, including, but not limited to:

Key Responsibilities

• Audit paid medical claims to identify overpayments using system queries, specialized reports, and manual research techniques 
• Conduct comprehensive research, analysis, and documentation of overpayment cases 
• Initiate and manage recovery efforts, including collection activities for overpayments and negative balance accounts 
• Collaborate with provider organizations to communicate findings and resolve overpayment issues 
• Interpret provider contracts to identify recovery opportunities and ensure compliance with contractual terms 
• Partner with contract management teams to address and correct reimbursement or contractual discrepancies 
• Serve as a liaison between cost containment teams, health plans, and high-profile providers to ensure timely and satisfactory resolution of recoveries 
• Investigate and resolve moderately complex overpayment cases and special projects 
• Assist with the review and resolution of state complaints related to overpayments or negative balances within mandated timelines 
• Coordinate with recovery and collection vendors to validate identified overpayments and review vendor invoices for accuracy 
• Analyze claims data and trends to detect payment errors and recommend process improvements 
• Provide feedback to improve audit queries, reporting tools, and recovery processes 
• Ensure all activities comply with company policies and applicable federal and state regulations. 

QUALIFICATIONS AND EDUCATION

Qualifications 

• Minimum of 4 years of relevant experience in healthcare claims, payment integrity, or recovery operations. 
• At least 3 years of cost containment experience preferred. 
• Strong knowledge of managed care claims processing and reimbursement methodologies. 
• Experience interpreting provider contracts and identifying payment discrepancies. 
• Familiarity with federal and state healthcare regulations. 

Skills & Competencies

• Strong analytical and problem-solving skills with attention to detail. 
• Effective communication and negotiation skills, particularly with providers. 
• Ability to manage multiple cases and meet strict deadlines. 
• Proficiency in claims systems, data analysis tools, and reporting platforms. 
• Strong organizational and documentation skills. 
• Commitment to accuracy, compliance, and customer satisfaction. 

Work Environment

• Fast-paced managed care environment that requires cross-functional collaboration. 
• Regular interaction with internal departments, providers, and external vendors.

WORKING CONDITIONS

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lifts, and moves intermittently during working hours. May be sitting for a prolonged period.

The work schedule is approximate, and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed. May require some OT during varying seasons of the year.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The employee must be able to frequently lift up to 10 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand and walk. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

PERFORMANCE MEASUREMENTS

This Job Description may be modified at any time at the discretion of the employer as business operations may deem necessary. This does not constitute an employment agreement and may not include all duties.

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified. The incumbent must be able to work in a fast-paced environment with a demonstrated ability to juggle and prioritize multiple competing tasks and demands and to seek supervisory assistance as appropriate.

Employee Acknowledgement:

 
I have read this job description and understand what is expected of me while I occupy this role.

Salary : $30 - $35