Claims Repricer

Position Summary

The Claims Repricer role focuses on carefully reviewing medical claims, correcting pricing where needed, and applying the right pricing rules and methodologies. The goal is to make sure each claim is aligned with provider contracts, fee schedules, and benefit design so that pricing remains accurate, rework is reduced, and claims operations run efficiently in a high-volume setting.

Key Responsibilities

• Examine medical claims and apply repricing rules accurately based on provider agreements, fee schedules, and reimbursement standards.
• Investigate pricing variances and make corrections so claims follow contractual and system requirements.
• Handle complex claim cases, including issues escalated by Provider Services and Claims Processing.
• Work with Configuration, Network Management, and Claims teams to troubleshoot pricing problems and system defects.
• Review contract language and apply it correctly within claims adjudication platforms.
• Meet expected standards for productivity, quality, and turnaround time in a fast-paced claims environment.
• Record analysis, adjustments, and resolution details in a clear, audit-ready manner.
• Spot pricing patterns and root causes, then suggest improvements that help reduce errors and rework.

Required Qualifications

• High school diploma or equivalent is required; an associate degree or bachelor’s degree is preferred.
• 2 to 4 years of experience in healthcare claims handling, pricing, or repricing.
• Working knowledge of claims adjudication processes and reimbursement approaches such as fee schedules and contract-based pricing.
• Prior experience reviewing provider contracts and pricing rules is preferred.
• Strong analytical thinking, troubleshooting ability, and attention to detail.
• Comfort managing changing workloads and prioritizing tasks effectively.
• Proficiency with Microsoft Excel, Word, and claims processing systems.

Additional Information

The employer is an equal opportunity employer and considers all qualified applicants without regard to age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.

An Android or iOS device compatible with the free Microsoft Authenticator app is required.