The Payment Review Subject Matter Expert (SME)is responsible forserving as the primary resource for complex payment review cases, payer reimbursement accuracy, and payment variance resolution. This role supports the Revenue Cycle team by ensuring payments are reviewed accurately and in compliance with payer contracts, policies, and regulatory guidelines, while maintaining established SLAs and quality standards.

Job Responsibilities

Reviews and analyzes complex, high-value, or escalated payment cases to ensure accurate reimbursement.
Validates payments against payer contracts, fee schedules, reimbursement methodologies, and policies.
Identifies under payments, over payments, and payment discrepancies;determines root causes and resolution steps.
Provides expert guidance to Payment Review Analysts on adjudication logic and reimbursement rules.
Assists with preparation of documentation and recommendations for appeals, reconsiderations, and payer disputes.
Performs quality reviews of payment review work to ensure accuracy, consistency, and compliance.
Escalates system, payer, or workflow issues to leadership in a timely manner.
Supports SOPs, job aids, and reference materials.
Ensures compliance with HIPAA and confidentiality standards.

Minimum Requirements

Bachelor's degree preferred.
Minimum of 3 years of experience with focus on payment review, reimbursement, or contract analysis.
Advanced knowledge of payer adjudication logic, reimbursement methodologies and payment variance resolution.
Strong understanding of claim life cycle and reimbursement principles.
Proficiency in RCM systems, payment review tools and Microsoft Office.
Excellent analytical, communication, and documentation skills.
Strong attention to detail, problem‑solving skills, and ability to manage high‑volume workloads.

Competencies

Fostering Teamwork
Analytical Thinking
Commitment to Job Deliverables
Leadership
Decision making
Trustworthiness and Ethics
Attention to Details
Problem Solving
Attention to Communication
Technical Expertise
Customer Orientation
Analytical Thinking
Managing Change
Adaptability
Managing Performance
Stress Management
Initiative
Personal Credibility
Interpersonal Skills
Flexibility

Required Skills

Excellent verbal and written communication skills
Ability to communicate complex reimbursement concepts clearly
Strong documentation and analytical commentary skills
Team-oriented with mentoring capability

Technical Skills

High attention to detail and analytical accuracy
Strong proficiency in Excel, Word, and Outlook
Knowledge of payer fee schedules, contracts, and reimbursement models
Strong computer skills and familiarity with payment review systems

Physical Abilities

Perform some repetitive motion activities.
Sit for long periods of time.
Requires close vision and the ability to adjust eye focus often.
Required to reach with hands and arms.

WORK SCHEDULE

Works at a standard workstation for extended periods
Uses standard computer equipment including keyboard and monitor
No lifting required for this position
Must report to work on time and complete assigned shift
Must be willing to work night shift as required by business needs

For further information, and to apply, please visit our website via the Apply button below.

Subject Matter Expert - Payment Review