Bham-Corporate Office
Birmingham, AL 35203, USA
Description Senior Payment Integrity Specialist
Location:
Birmingham, AL
Why VIVA HEALTH?
VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys.
VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan and has been repeatedly ranked as one of the nation's Best Places to Work by Modern Healthcare.
Comprehensive Health, Vision, and Dental Coverage
401(k) Savings Plan with company match and immediate vesting
Paid Time Off (PTO)
9 Paid Holidays annually plus a Floating Holiday to use as you choose
Tuition Assistance
Flexible Spending Accounts
Community Service Time Off
Life Insurance and Disability Coverage
Employee Wellness Program
Training and Development Programs to develop new skills and reach career goals
The
Senior Payment Integrity Specialist
is responsible for leading complex payment integrity activities to ensure accurate reimbursement of claims and minimizing financial risk for the health plan. This position provides oversight of third-party payment integrity vendors, performs advanced claims pricing and reimbursement analysis, and supports high-dollar, complex adjustments and recoupments.
This individual serves as a subject matter expert, partnering with internal stakeholders to resolve escalated issues, improve payment accuracy, and strengthen payment integrity controls while ensuring compliance with contractual and regulatory requirements.
Key Responsibilities
Serve as subject matter expert for vendor-supported payment integrity activities.
Perform independent analysis of complex pricing and reimbursement scenarios.
Resolve discrepancies related to Diagnosis-Related Groups (DRG), Ambulatory Payment Classifications (APC), case rates, stop-loss, and fee schedules.
Determine appropriateness of recoupment actions for complex or high-dollar cases.
Support resolution of provider disputes and appeals related to payment integrity findings.
Identify systemic payment issues and recommend corrective actions.
Partner with Claims, Configuration, Contracting, and Compliance to prevent recurring errors.
Lead initiatives to improve payment accuracy and recovery outcomes.
Provide guidance and training to Payment Integrity team.
Serve as escalation point for complex or sensitive issues.
REQUIRED:
High School diploma or GED
At least 3–5 years of healthcare claims processing experience, including adjustments or payment research
Advanced understanding of claims pricing, reimbursement methodologies, and payment policies
Proficiency with claims systems and Microsoft Office applications
Strong attention to detail and accuracy
Effective written and verbal communication
Strong organizational and time-management skills
Ability to work independently within defined guidelines
Ability to evaluate complex and high-dollar payment integrity findings
Working knowledge of claim edits, payment methodologies, and adjustment workflows
Knowledge of Centers for Medicare & Medicaid Services (CMS) guidelines and payer payment policies
PREFERRED:
Associates degree or higher
Experience in payment integrity, recovery auditing, or overpayment recovery
Experience working with payment integrity or audit vendors
Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
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Description Senior Payment Integrity Specialist
Location:
Birmingham, AL
Why VIVA HEALTH?
VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys.
VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan and has been repeatedly ranked as one of the nation's Best Places to Work by Modern Healthcare.
Comprehensive Health, Vision, and Dental Coverage
401(k) Savings Plan with company match and immediate vesting
Paid Time Off (PTO)
9 Paid Holidays annually plus a Floating Holiday to use as you choose
Tuition Assistance
Flexible Spending Accounts
Community Service Time Off
Life Insurance and Disability Coverage
Employee Wellness Program
Training and Development Programs to develop new skills and reach career goals
The
Senior Payment Integrity Specialist
is responsible for leading complex payment integrity activities to ensure accurate reimbursement of claims and minimizing financial risk for the health plan. This position provides oversight of third-party payment integrity vendors, performs advanced claims pricing and reimbursement analysis, and supports high-dollar, complex adjustments and recoupments.
This individual serves as a subject matter expert, partnering with internal stakeholders to resolve escalated issues, improve payment accuracy, and strengthen payment integrity controls while ensuring compliance with contractual and regulatory requirements.
Key Responsibilities
Serve as subject matter expert for vendor-supported payment integrity activities.
Perform independent analysis of complex pricing and reimbursement scenarios.
Resolve discrepancies related to Diagnosis-Related Groups (DRG), Ambulatory Payment Classifications (APC), case rates, stop-loss, and fee schedules.
Determine appropriateness of recoupment actions for complex or high-dollar cases.
Support resolution of provider disputes and appeals related to payment integrity findings.
Identify systemic payment issues and recommend corrective actions.
Partner with Claims, Configuration, Contracting, and Compliance to prevent recurring errors.
Lead initiatives to improve payment accuracy and recovery outcomes.
Provide guidance and training to Payment Integrity team.
Serve as escalation point for complex or sensitive issues.
REQUIRED:
High School diploma or GED
At least 3–5 years of healthcare claims processing experience, including adjustments or payment research
Advanced understanding of claims pricing, reimbursement methodologies, and payment policies
Proficiency with claims systems and Microsoft Office applications
Strong attention to detail and accuracy
Effective written and verbal communication
Strong organizational and time-management skills
Ability to work independently within defined guidelines
Ability to evaluate complex and high-dollar payment integrity findings
Working knowledge of claim edits, payment methodologies, and adjustment workflows
Knowledge of Centers for Medicare & Medicaid Services (CMS) guidelines and payer payment policies
PREFERRED:
Associates degree or higher
Experience in payment integrity, recovery auditing, or overpayment recovery
Experience working with payment integrity or audit vendors
Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
#J-18808-Ljbffr