Lead, Medical Network Claims Pricer

Location: Hybrid (at least 3 days per week in our NYC, Denver, or Charlotte offices)

Position Summary

The Lead, Medical Network Pricer serves as the subject matter expert for medical claim pricing within a technology-enabled healthcare environment. The Medical Network Pricer interprets contract and provider reimbursement terms and has a command of various provider reimbursement methodologies.  This role can then apply these terms to claims data, considering the application of coding requirements, fee schedules, payment and reimbursement policies.  This role can define and document pricing rules; prepares, validates, and maintains reimbursement data sets for Judi ingestion; and resolves claims requiring exception handling. The role can manually price professional, facility, ancillary, anesthesia, dialysis, behavioral health, laboratory, durable medical equipment, and other medical claims using industry-standard reimbursement methodologies, including Medicare-based pricing and Reference-Based Pricing (RBP). In partnership with Product and Engineering, the role translates manual pricing logic, decision points, and operational controls into requirements for scalable, automated platform capabilities. The role operates with substantial autonomy and is accountable for accurate, consistent, auditable pricing outcomes affecting clients, providers, members, and enterprise financial results.

Position Responsibilities:

Medical Network Pricing Strategy & Execution

• Interprets complex provider contract language, reimbursement terms and methods and translates to pricing rules that can be consumed by engineering team.
• Has a deep understanding of reimbursement and payment policies that govern coding and payment policies.
• Advises on code sets and tables that must be sourced and maintained for accurate pricing.
• Manually prices complex professional, inpatient, outpatient, ambulatory surgical center, anesthesia, dialysis, ancillary, behavioral health, laboratory, home health, and durable medical equipment claims in accordance with client requirements and approved reimbursement methodologies.
• Apply Medicare-based pricing, Reference-Based Pricing (RBP), fee schedules, resource-based relative value methodologies, diagnosis-related groups, ambulatory payment classifications, per-diem rates, case rates, percent-of-charge arrangements, stop-loss provisions, and other approved reimbursement approaches.
• Research and determine appropriate reimbursement when claims contain incomplete, conflicting, unusual, or nonstandard coding, provider, service, or payment information.
• Define, document, validate, and maintain pricing rules, calculation steps, data dependencies, assumptions, and decision criteria used to produce consistent and reproducible claim outcomes.
• Lead pricing support for new client implementations, reimbursement programs, fee-schedule updates, claim types, migrations, and platform enhancements.
• Establish quality reviews, approval controls, and monitoring routines that protect manual and automated claim-pricing accuracy and financial integrity.

Pricing Rules, Reimbursement Data & Platform Configuration

• Interpret client reimbursement requirements, provider agreements, payment policies, plan provisions, and government program rules; translate applicable provisions into documented pricing logic and operational instructions.
• Prepare, validate, reconcile, and maintain reimbursement data sets, fee schedules, geographic adjustments, code mappings, rate tables, and supporting reference files for Judi ingestion.
• Assess provider identifiers and classifications, places of service, procedure and revenue codes, modifiers, diagnosis codes, units, claim types, status indicators, bundling rules, and other data elements that influence reimbursement.
• Create pricing matrices, calculation workbooks, decision tables, configuration specifications, test scenarios, expected results, and traceable documentation for operational and technical use.
• Manage reimbursement-data updates through defined version control, validation, approval, ingestion, and post-deployment review processes.
• Evaluate downstream impacts of pricing-rule or reimbursement-data changes on claim adjudication, provider payments, client billing, benefit application, reconciliation, reporting, and member cost share.

Exception Handling, Analysis & Reporting

• Review claims routed for manual pricing or exception handling; research source data, applicable reimbursement rules, and supporting documentation to determine the correct allowed amount.
• Identify recurring exception patterns, data deficiencies, unsupported claim scenarios, and pricing-rule gaps; recommend interim controls and durable process or platform solutions.
• Conduct root-cause analysis of pricing discrepancies and determine corrections, financial remediation, data updates, rule changes, and control improvements.
• Reconcile manual calculations against Judi-generated outcomes and source reimbursement data to confirm accuracy before and after automation releases.
• Build and interpret exception reports, pricing reconciliations, quality metrics, dashboards, and summaries that communicate volumes, trends, financial exposure, root causes, and recommended actions.
• Escalate material pricing risks, unresolved policy questions, and high-impact exceptions with clear analysis and recommended disposition.

Subject Matter Leadership & Pricing Automation

• Serve as the authoritative resource for manual medical claim pricing, Medicare-based reimbursement, Reference-Based Pricing, reimbursement data, pricing exceptions, and claim-pricing controls.
• Partner closely with Product and Engineering to decompose manual pricing workflows into business rules, data requirements, calculation logic, decision points, exception paths, acceptance criteria, and control requirements for Judi.
• Prioritize automation opportunities based on claim volume, operational effort, financial exposure, repeatability, data readiness, and client impact.
• Provide subject matter guidance during solution design, refinement, development, user acceptance testing, defect triage, release readiness, and post-production validation.
• Compare automated outputs with independently calculated expected results, document variances, and approve pricing behavior when established acceptance criteria are met.
• Develop standards, playbooks, and training materials that enable consistent manual pricing and support the transition of repeatable work into scalable platform capabilities.

Compliance & Quality

• Ensure medical network pricing practices and configurations align with provider contracts, client commitments, applicable federal and state requirements, coding standards, and internal governance.
• Maintain complete, auditable documentation of assumptions, approvals, testing evidence, pricing decisions, exceptions, and remediation activities.
• Support internal, client, provider, regulatory, and financial audits; prepare evidence and explain methodologies and outcomes.
• Monitor evolving payer reimbursement requirements, coding updates, government fee schedules, and industry developments; determine operational impact and recommend timely contract, policy, process, or system changes.
• Identify control gaps and lead process improvements that increase scalability, transparency, accuracy, and speed.

Required Qualifications:

• Bachelor’s degree in finance, economics, business, healthcare administration, health information management, data analytics, mathematics, information systems, or a related field required.
• Seven or more years of progressive experience in medical claim pricing, provider reimbursement, medical claims analysis, payment integrity, managed-care pricing, or a closely related function, including direct responsibility for complex manual claim calculations.
• Subject matter expertise in Medicare-based reimbursement, Reference-Based Pricing, professional and institutional claim pricing, fee-schedule administration, and healthcare payment methodologies.
• Advanced knowledge of procedure, revenue, diagnosis, and modifier logic; physician fee schedules; resource-based relative value methodologies; diagnosis-related groups; ambulatory payment classifications; per-diem, case-rate, percent-of-charge, and other medical reimbursement arrangements.
• Demonstrated ability to manually calculate allowed amounts, resolve ambiguous pricing scenarios, and explain calculation methods and assumptions in clear, auditable documentation.
• Experience preparing, validating, reconciling, and maintaining reimbursement data sets, fee schedules, code mappings, and rate tables for system ingestion.
• Demonstrated ability to convert manual operational workflows into business rules, technical requirements, test cases, expected results, and acceptance criteria for Product and Engineering teams.
• Advanced proficiency with Microsoft Excel and large-data analysis; experience with SQL, business intelligence tools, claims-pricing platforms, or comparable analytics solutions.
• Strong written and verbal communication skills, including the ability to explain complex reimbursement calculations to operational, client-facing, Product, Engineering, Compliance, and leadership audiences.

Preferred Qualifications:

• Experience in a health plan, third-party administrator, healthcare technology organization, provider network, or medical claims platform.
• Experience with government programs, including Medicare Advantage, Original Medicare, or Medicaid provider reimbursement requirements.
• Experience with provider network negotiations, fee-schedule maintenance, contract modeling, value-based reimbursement, payment bundling, out-of-network pricing, and claim-pricing reconciliation.
• Experience defining requirements for cloud-based medical claims, pricing, data, or decision-support products in an Agile product-development environment.
• Graduate degree, CPA, CFA, Certified Professional Coder, Certified Professional Medical Auditor, or relevant managed-care, analytics, or project-management certification.