Pricing Resolution Processor II

**About MedReview** ------------------- MedReview is a leading provider of payment integrity solutions that help national and regional health plans promote population health, ensure payment accuracy, reduce administrative waste, improve provider relationships, and optimize financial performance. For more than four decades, MedReview has partnered with health plans, third\-party administrators, and other healthcare organizations to deliver technology\-enabled solutions that identify savings opportunities, drive operational efficiency, and improve healthcare outcomes. **The Opportunity** ------------------- MedReview is seeking a **Pricing Resolution Processor II** to join our Payment Integrity Operations team. This role is responsible for reviewing, grouping, and pricing routine healthcare facility claims to identify potential overpayments and ensure reimbursement accuracy. The Pricing Resolution Processor II applies client\-specific reimbursement methodologies, payer requirements, regulatory guidelines, and internal operational standards to support accurate and timely claim pricing decisions. The ideal candidate will possess healthcare claims processing experience, strong analytical skills, and a high level of attention to detail. This position requires the ability to evaluate claim information, identify discrepancies, validate data accuracy, and ensure compliance with reimbursement policies and contractual obligations while maintaining productivity and quality standards in a high\-volume environment. **This position is remote. Candidates must maintain a secure workspace that protects protected health information (PHI) and HIPAA\-regulated data.** **Key Responsibilities** ======================== **Claims Review and Validation** -------------------------------- * Review assigned healthcare claims for completeness, accuracy, and eligibility for review. * Validate claim information and supporting documentation before pricing activities begin. * Analyze claim details to ensure all required information has been submitted and appropriately documented. * Identify missing, inaccurate, or inconsistent claim data and initiate appropriate resolution steps. * Maintain high levels of accuracy while managing assigned workloads and turnaround expectations. **Claim Grouping and Pricing** ------------------------------ * Group facility claims using client and internal systems in accordance with established methodologies. * Apply reimbursement methodologies based on client requirements, regulatory guidance, and contractual obligations. * Ensure claims are priced accurately and consistently according to payer\-specific guidelines. * Review claim information to identify potential overpayments and reimbursement discrepancies. * Utilize internal applications and client platforms to support pricing and claim review activities. **Compliance and Quality Assurance** ------------------------------------ * Ensure adherence to payer contract requirements, reg