Solution Specialist, Payment Intelligence

Health plans face continued challenges in reimbursing claims on-time and accurately. AArete's consulting service line, Payment Intelligence, goes beyond typical payment integrity to ensure erroneous and inefficient payments are identified, rectified, and recouped to prevent them in the future.

In this role, the individual will be responsible for delivering claims analytics and post-pay data mining edits for client engagements. The position will report to a Payment Intelligence Manager. The individual will be the subject matter expert on strategies to help our clients ensure proper claims payment through the use of (1) claims analytics, (2) process improvements, (3) integration of automation/technology, and (4) configurations setups. This role will support the internal development of Payment Intelligence initiatives.

Work You'll Do

• Support the development, identification and analysis of payment accuracy opportunities through remediation
• Utilize analytics to identify claims payment opportunities through your knowledge of standard payment methodologies including Prospective Payment Systems (IPPS/OPPS), fee for service, Groupers, RUG, etc.
• Support process improvements and automation initiatives
• Conduct research on current events, changes in regulatory requirements and market trends impacting health plan reimbursement
• Contribute to the preparation of client ready deliverables with clear and actionable insight
• Exercise sound judgement and clear and direct communication in all aspects of your work
• Other duties as assigned

• 2+ years of experience in payment integrity, healthcare analytics, or payer operations
• Foundational knowledge of claims processing across multiple lines of business, including Medicare, Medicaid, ACA/Marketplace, Commercial, and Duals
• Experience across various spend areas (professional, ancillary, outpatient, and inpatient), familiarity with modifiers, place of service codes, and NPI/TIN relationships
• Ability to identify incorrect claims payments
• Knowledge of industry vendors and tools related to claims processing, provider data, and contract management
• Understanding of end-to-end claims processes, including claims management, provider lifecycle, and network optimization
• Strong professional communication skills, including written, verbal, interpersonal, and in-person presentation expertise
• Advanced proficiency utilizing Microsoft Excel
• Strong analytical, data interpretation, and problem-solving skills
• Ability to identify client savings opportunities and develop actionable business cases
• Strong working knowledge of managed care claims coding (Current Procedural Terminology (CPT), International Classification of Diseases (ICD), Healthcare Common Procedure Coding System (HCPCS), Revenue Codes), and federal/state Medicaid payment rules
• Bachelor's Degree or additional years of experience in lieu of degree
• Must be legally authorized to work in the United States without the need for employer sponsorship

Preferred Requirements

• Policy & Claims Editing Expertise

• Research and interpretation of healthcare policies and regulations
• Experience in reimbursement policy writing and claims editing
• Proficiency in data mining to detect errors and inconsistencies
• Ability to crosswalk and compare edits and policies
• Knowledge of claims editing processes, including Prepay/Post-Pay, COB, Subrogation, Fraud Detection, and Medical Record Reviews

• Contract Configuration & Provider Data Expertise

• Interpretation of provider contract terms and pricing methodologies, including fee schedules, per diem, DRGs, cost-plus, and outlier payments
• Understanding of contract carve-outs, including bundled services, readmissions, and reductions
• Experience in contract pricing and claims reimbursement analysis
• Ability to price and reprice claims based on contractual agreements
• Understanding of provider TIN and NPI relationships
• Familiarity with network processes, including Optimization, Adequacy, and Pricing

• Familiarity with claims adjudication systems (e.g., Facets, QNXT, Amisys, etc.)
• Experience with SQL or other query languages
• Experience in reimbursement policy
• Knowledge of COB, Subrogation, Fraud Detection, and Medical Record Reviews
• Experience with financial impact modeling, savings forecasting, and ROI analysis
• Exposure to AI/ML models for aberrant billing pattern detection
• Understanding of EDI formats (837/835) and how errors propagate through the claim lifecycle
• Familiarity with industry vendors
• Based in Chicago, IL, and flexible to work from our Chicago office as needed

Compensation & Benefits

• Flexible PTO, monthly half-day refuels, volunteer time off, 10 paid holidays
• Own Your Day flexible work policy
• Competitive majority employer-paid benefits: Medical, Dental, Vision, 401K Match
• Generous paid parental leave options
• Employer paid Life Insurance, STD, LTD
• Charitable contribution matching program
• New client commission opportunities and referral bonus program
• Bike share discount program

The estimated base salary range for this position is $75,000 - $105,000. In addition to this base salary, individuals may be eligible for an annual discretionary bonus. This range is a part of a competitive, total compensation package together with our majority employer-paid benefits and incentive pay for eligible roles. Please note that this range is a guideline and individual total compensation may vary due to numerous factors including but not limited to experience level, certifications, and other relevant business considerations.

AArete is one-of-a-kind when it comes to consulting firm culture. We're a global, innovative management and technology consulting firm with offices in the U.S., India, and Europe. Our name comes from the Greek word for excellence: "Arete." And excellence is exactly what we strive for. We're celebrating our fourth year as one of Forbes' World's Best Management Consulting Firms - and our success starts with our people. From robust career development planning to competitive life and wellness benefits, AArete's "Culture of Care" takes a holistic approach to the employee experience. AAretians (our team members) are leaders at every level. You are encouraged to unlock your full potential by directly contributing to our mission and prioritizing personal development and fulfillment., We're a global management and technology consulting firm specializing in strategic profitability improvement, digital transformation, and strategy & change for clients. Our cross-industry solutions are powered by a digital-first mindset, market intelligence, and data-driven approach to deliver purposeful change, actionable insights, and guaranteed results. But what sets us apart is our people. We are guided by our deeply embedded guiding principles: Excellence, Passion, Loyalty to Clients, Stewardship, Family, Community, Sustainability, and Inclusion. And we've been recognized as a top firm to work for by companies like Forbes, Top Workplaces Chicago Tribune, and Consulting Magazine. We've earned a Great Place to Work Certification and been named a World's Best Management Consulting Firm by Forbes, Vault's Top 50 Firms to Work For, Crain's Chicago Business Fast 50, Inc 5000's Fastest Growing Firms, and Consulting Magazine's Fastest Growing Firms.