[Hiring] Healthcare Claims Pricing & Payment Integrity Specialist @Sagility

Role Description

This role involves supporting and enhancing the claims repricing platform at Sagility Payment Integrity Solutions.

• Research and interpret CMS reimbursement rules, state payment guidelines, and fee schedules
• Translate payer and provider contract terms into pricing logic and audit approaches
• Develop and refine repricing methodologies used to identify potential overpayments
• Write and execute complex SQL queries to analyze claims and validate pricing outcomes
• Investigate pricing variances and support audit findings
• Partner with SQL engineering team to operationalize and scale pricing logic
• Collaborate with audit, operations, and analytics teams to ensure defensible results
• Document pricing logic, assumptions, and decision frameworks

Qualifications

• Experience in healthcare claims repricing, reimbursement, payment integrity, medical economic experience, or claims analytics
• Strong understanding of CMS reimbursement methodologies
• State payment rules
• Fee schedules and contract-driven pricing
• Experience working directly with claims datasets in a production or operational environment
• Ability to research and interpret reimbursement guidance without fully defined requirements
• Strong analytical and investigative mindset
• Ability to write complex SQL queries for data analysis and validation
• Familiarity with DRG, APC, Medicare/Medicaid pricing, and commercial reimbursement models

Requirements

• Experience with payment integrity vendors, health plans, or 3rd party administrators
• Experience supporting overpayment detection or claims audit workflows
• Experience working alongside SQL engineering or data platform teams

Ideal Candidate Profile

• Deep understanding of how healthcare claims are priced and reimbursed
• Comfortable translating policy, contracts, and fee schedules into actionable logic
• Strong investigator who can work from incomplete inputs
• Data-driven and good SQL Query skills
• Thrives in operational environments where accuracy and defensibility matter

Success in This Role

• Improves accuracy and consistency of repricing and overpayment detection
• Independently researches and implements new reimbursement logic
• Partners effectively with SQL engineering to operationalize pricing rules
• Strengthens documentation and reduces reliance on institutional knowledge

Location

Work@Home USA, United States of America