Subject Matter Expert - Payment Review

JOB DESCRIPTION:

The Payment Review Subject Matter Expert (SME) is responsible for serving 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 underpayments, overpayments, 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 

The base pay for this position is

N/A

In specific locations, the pay range may vary from the range posted.

     

JOB FAMILY:

Accounts Payable & Receivables, Credit & Collection, & Payroll

DIVISION:

HF Heart Failure

LOCATION:

Philippines > Taguig City : Five/Neo Building

ADDITIONAL LOCATIONS:

WORK SHIFT:

Standard

TRAVEL:

Not specified

MEDICAL SURVEILLANCE:

Not Applicable

SIGNIFICANT WORK ACTIVITIES:

Continuous sitting for prolonged periods (more than 2 consecutive hours in an 8 hour day)