Claims Repricer

Position Summary

The Claims Repricer is responsible for reviewing, analyzing, and repricing medical claims according to provider contracts, fee schedules, and client-specific reimbursement arrangements. This role ensures claims are priced accurately, efficiently, and in compliance with contractual and regulatory requirements.

Essential Duties and Responsibilities

Claims Review and Repricing

• Review and reprice professional (HCFA) and institutional (UB-04) medical claims.
  
• Apply provider contract terms, fee schedules, reimbursement methodologies such as case rates, per diem, DRGs, APCs, ASC rates, and percentage-of-charge agreements.
  
• Analyze claim details, coding, and reimbursement methodologies to determine accurate payment allowances.
  
• Ensure claims are processed in accordance with network agreements and client-specific requirements.
  

Research and Resolution

• Investigate and resolve claim pricing discrepancies and reimbursement questions.
  
• Review contract language and reimbursement methodologies to support accurate pricing decisions.
  
• Evaluate reconsideration requests and identify pricing corrections when appropriate.
  
• Research coding edits, reimbursement issues, and claim exceptions.
  

Quality and Compliance

• Maintain high levels of pricing accuracy and adherence to established workflows.
  
• Ensure compliance with internal policies, provider agreements, and reimbursement guidelines.
  
• Document pricing decisions and supporting rationale as required.
  
• Participate in quality audits and corrective action activities when necessary.
  

Collaboration and Communication

• Work closely with Provider Relations, Contracting, Operations, and Information Technology teams to resolve claim issues.
  
• Respond to internal inquiries regarding claim pricing and reimbursement methodologies.
  
• Communicate effectively regarding claim status, pricing determinations, and issue resolution.
  

Process Improvement

• Identify trends, recurring issues, and opportunities to improve pricing accuracy and efficiency.
  
• Assist with testing, implementation, and validation of new contracts, fee schedules, and pricing methodologies.
  
• Support departmental initiatives aimed at improving turnaround times and operational effectiveness.
  

Requirements

Qualifications

• High school diploma or equivalent required; Associate's or Bachelor's degree preferred.
  
• Minimum of two years of experience in medical claims processing, medical billing, healthcare reimbursement, or claim repricing preferred.
  
• Knowledge of CPT, HCPCS, ICD-10, DRG, APC, and revenue codes preferred.
  
• Experience interpreting provider contracts and reimbursement methodologies preferred.
  
• Familiarity with Medicare reimbursement methodologies and healthcare payment systems.
  
• Strong analytical and problem-solving skills.
  
• Proficiency with Microsoft Excel and claims processing software.
  
• Excellent organizational, communication, and time-management skills.
  

Preferred Qualifications

• Experience in a Third-Party Administrator (TPA), PPO network, health plan, or healthcare reimbursement environment.
  
• Experience pricing claims using DRG, APC, ASC, case rate, per diem, stop-loss, percentage-of-charge, and Medicare-based reimbursement methodologies.
  
• Knowledge of claim editing guidelines, including NCCI edits and modifier usage.
  

Benefits

• Health Insurance
  
• Dental Insurance
  
• Vision Insurance
  
• Paid Time Off (PTO)
  
• Employee Assistance Program (EAP)
  
• 401(k) with 7% Employer Contribution
  
• Health Savings Account (HSA)
  
• Referral Program
  
• Life Insurance
  
• Discounted Gym Membership
  
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