Senior Executive – Audit Operations

The Senior Executive will be responsible for ensuring accurate identification of a clients claim payment anomalies by obtaining the clients provider agreements and contract loading, researching and flagging discrepancies, and validating claims for payment integrity. This role involves collaborating with various departments, using system tools to load contracts, identify claim anomalies, and ensure compliance with healthcare regulations and company policies. The specialist will play a key role in ensuring claims anomalies are accurately and efficiently identified and submitted to the client for recovery of the overpaid claims.

Key Area of Responsibilities:

Contract Loading & Maintenance:

• Accurately load, configure, and maintain healthcare provider contracts within the audit and claims systems, ensuring alignment with contractual terms.
• Review and update contract details including fee schedules, reimbursement rates, and payment terms to support accurate claims adjudication.
• Ensure timely and precise updates to contract data, reflecting the most current agreement terms and minimizing payment discrepancies.

Claims Flagging:

• Review claims flagged by the audit system as potentially overpaid to confirm validity and ensure they meet overpayment criteria.
• Validate the allowed claim amount against independent sources outside of both the client and Sagility to ensure objective verification.
• Identify and flag claims that appear non-compliant with contract terms, benefit rules, or established payment policies.
• Investigate potential billing errors or coding discrepancies that may contribute to inaccurate payments.

Contractual Claims Audit & Contract Load Validation:

• Review paid claims for accuracy and identify confirmed overpayments, minimizing false positives through thorough validation protocols.
• Support quality audit efforts by refining claim review criteria and contributing to process improvements that enhance the accuracy of flagged claims.
• Actively work to reduce false positives and improve the true positivity rate of flagged claims by applying data-driven insights and validation best practices.

Data Analysis & Reporting:

• Assist the team to identify areas for new audit opportunities as well as areas for further automation or operational efficiency
• Generate reports on flagged claims, underpayments, overpayments, and any trends or issues related to payment integrity.
• Analyze data to detect patterns of claims issues, providing actionable insights to improve payment accuracy and integrity.
• Assist in audits and investigations related to payment integrity.

Collaboration & Communication:

• Collaborate with cross-functional teams, including Provider Services, Claims Adjudication, and IT, to resolve payment integrity issues.
• Communicate effectively with providers, healthcare professionals, and other stakeholders regarding contract terms and payment issues.

Compliance & Quality Assurance:

• Ensure compliance with applicable healthcare regulations, contract terms, and company policies in all payment integrity activities.
• Stay updated on industry regulations, payment integrity best practices, and any changes to contract management processes.

Education & Experience:

• Graduation or equivalent (required).
• 4+ years of experience in healthcare and claims adjudication.
• 2+ years of experience in Prepay/Post-pay Payment Integrity, Data Mining or Contract Audit
• Knowledge of healthcare reimbursement systems, payer-provider contracts, and claims adjudication processes is a plus.

Skills & Competencies:

• Strong understanding of contract rate loading and healthcare payment processing systems, with the ability to interpret and apply complex provider agreements.
• Highly detail-oriented with strong analytical and problem-solving capabilities, especially in identifying payment discrepancies and root causes.
• Proficient in Microsoft Office Suite, particularly Excel (e.g., pivot tables, formulas, VLOOKUP), along with Word and Outlook for documentation and communication.
• Hands-on experience with healthcare claims platforms such as Facets, TriZetto, or similar systems used in US healthcare operations.
• Excellent verbal and written communication skills, enabling effective collaboration with internal teams and external stakeholders.

Strong organizational and time management skills, with the ability to handle multiple priorities and meet tight deadlines in a dynamic environment