Payment Integrity Project Specialist

Job Summary

We are seeking an experienced Payment Integrity Specialist to support healthcare claims accuracy, payment validation, and operational improvement initiatives across complex healthcare environments. This role is responsible for managing and coordinating payment integrity projects, ensuring adherence to SLA agreements, collaborating with cross-functional teams, and supporting initiatives related to claims analysis, auditing, and reimbursement accuracy.

The ideal candidate will have strong experience within healthcare claims operations, project coordination, and payment integrity programs. This individual will work closely with operational leaders, vendors, business stakeholders, and technical teams to support process improvements, issue resolution, compliance efforts, and successful project execution.

Key Responsibilities

• Support and coordinate payment integrity initiatives focused on claims accuracy, overpayment prevention, and reimbursement validation.
• Manage and track project timelines, deliverables, risks, issues, and dependencies to ensure successful project execution.
• Ensure compliance with SLA agreements and operational performance expectations.
• Collaborate with cross-functional business, operational, technical, and vendor teams to support implementation and process improvement initiatives.
• Analyze healthcare claims data, workflows, procedures, and outcomes to identify trends, discrepancies, and opportunities for improvement.
• Coordinate activities between stakeholders, vendors, and internal departments to ensure alignment and timely delivery of project objectives.
• Assist with documentation of business requirements, workflows, operational procedures, and project status reporting.
• Support process improvement initiatives related to claims operations, reimbursement accuracy, and payment integrity programs.
• Participate in issue resolution, escalation management, and stakeholder communications.
• Maintain compliance with healthcare regulations, organizational policies, and project governance standards.

Required Qualifications

• Bachelor's degree or equivalent experience.
• 3+ years of experience within healthcare claims, payment integrity, healthcare operations, or related environments.
• Experience supporting or managing projects within healthcare or payer organizations.
• Strong understanding of:
  • Healthcare claims processing
  • Payment integrity operations
  • SLA agreements
  • Project management methodologies
  • Cross-functional coordination
• Experience working with healthcare data, claims systems, or reimbursement workflows.
• Strong analytical, organizational, communication, and problem-solving skills.
• Ability to manage multiple priorities in a fast-paced environment.

Preferred Qualifications

• Experience with:
  • Clinical editing
  • CMS regulations and processes
  • Medical coding
  • Payment integrity programs and audits
• PMP certification or formal project management training.
• Experience working with healthcare payer systems or reimbursement platforms.
• Knowledge of claims auditing, fraud/waste/abuse prevention, or overpayment recovery initiatives.

Additional Skills & Competencies

• Strong attention to detail and ability to analyze complex claims scenarios.
• Ability to collaborate effectively across operational and technical teams.
• Experience driving process improvement and operational efficiency initiatives.
• Excellent documentation, communication, and stakeholder management skills.
• Ability to adapt in a rapidly changing healthcare environment.