Payment Integrity Specialist

About the role   The Payment Integrity Specialist ensures that the claims and payments flowing through Cityblock’s value-based arrangements are accurate, appropriate, and compliant. Working across the claims and reimbursement lifecycle, the role identifies payment discrepancies — overpayments, underpayments, and improper payments — determines their root causes, and drives both recovery and prevention. Cityblock operates in risk-bearing, value-based arrangements with managed care organizations serving complex Medicaid, Medicare Advantage, and Dually Eligible populations. Payment integrity therefore spans two sides: ensuring Cityblock is reimbursed correctly by payers under capitation, kick-payment, and value-based settlements, and ensuring the medical claims that count against Cityblock’s cost and performance are accurate and free of error, waste, or abuse; all adhering to the value based contracts supporting the partnerships. This is a detail-intensive, analytical role that combines claims and coding knowledge, data analysis, and command of CMS and state Medicaid reimbursement rules. Success requires precision, an investigative mindset, and the ability to translate findings into recoveries and durable process improvements in partnership with finance, actuarial, partner success, and clinical teams.

Claim & Payment Accuracy Review Payment Audits: Review claims and encounters against contract terms, policy, CMS and Medicaid guidelines, and coding standards to confirm accuracy. Discrepancy Identification: Identify overpayments, underpayments, duplicate payments, and improper payments, documenting findings clearly and defensibly. Expected vs. Actual Reimbursement: Reconcile expected reimbursement against actual payments across capitation, value-based, kick-payment, and fee-for-service arrangements, and investigate variances.   Root-Cause Analysis & Prevention Edit & Rule Logic: Help define, validate, and refine payment-integrity edits and rules (pre-pay edits and post-pay analytics) to catch errors earlier in the process. Root-Cause Analysis: Determine the systemic sources of payment errors and recommend process, configuration, or contracting fixes that prevent recurrence. Process Improvement: Partner with stakeholders to operationalize corrective actions and track their impact over time.   Fraud, Waste & Abuse and Compliance FWA Detection: Surface potential fraud, waste, and abuse patterns in claims data and escalate them in line with policy to Actuary, Finance, Partner Success, and Payor teams. Regulatory & Contract Compliance: Ensure reviews and recoveries align with CMS, state Medicaid, and contract-specific requirements. Audit-Ready Documentation: Maintain rigorous documentation of findings, methodologies, and recoveries to support investigation. Analytics, Reporting & Collaboration Data Analysis: Analyze claims, encounter, and payment data to identify trends, quantify financial impact, and prioritize the highest-value opportunities. Reporting: Build and maintain reports and dashboards that track payment-integrity findings, recoveries, and prevention outcomes. Cross-Functional Partnership: Collaborate with finance, actuarial, market, partner success teams to resolve issues and align on standards.

Bachelor’s degree in finance, healthcare administration, business, health information management, or a related field; relevant certification (e.g., CPC, CFE, AHFI) a plus. 3+ years in payment integrity, claims auditing, revenue cycle, medical economics, health-plan or provider claims analysis. Claims & Coding Knowledge: Working knowledge of the healthcare claims lifecycle and coding systems (CPT, HCPCS, ICD-10, DRG), and familiarity with CMS and state Medicaid reimbursement rules. Value-Based & Managed Care: Exposure to value-based, capitation, or managed-care arrangements strongly preferred; Medicaid experience a plus. Analytical Tools: Strong Excel skills; SQL or