Healthcare Claims Pricing & Payment Integrity Specialist

Sagility Payment Integrity Solutions LLC • Full-time • Remote (Work@Home USA, United States of America) • 1w ago

Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries. Job title: Healthcare Claims Pricing & Payment Integrity Specialist Job Description: Position Overview: Sagility Payment Integrity Solutions specializes in identifying provider overpayments for health plans. Our internal claims repricing platform recalculates reimbursement using CMS and state guidance, rates and fee schedules, and plan/provider contract terms. We are seeking a technical healthcare claims pricing & payment integrity specialist to support and enhance this work. This is a domain-driven, hands-on role focused on understanding and researching reimbursement methodologies, translating them into pricing logic, and validating outcomes using data and SQL queries. The role partners closely with the SQL engineering/development team to enhance and evolve the current system. This position is ideal for someone from the payment integrity, payer reimbursement, or claims analytics space who is comfortable working directly with claims data and technical systems. Key Responsibilities 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 Required 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 Preferred Qualifications 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 USAUnited States of America Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries.