Payment Integrity Specialist

About Council Capital and Alivia Analytics

Council Capital is a Nashville-based private equity firm managing over $350 million in capital, investing in healthcare companies valued between $10 million and $100 million. They utilize the Council Model, which combines seasoned CEO advisors, strategic investors, and an internal value creation team to support leadership and scale businesses that enhance healthcare outcomes.

Alivia Analytics, a portfolio company, is a healthcare technology firm specializing in combating fraud, waste, and abuse through its AI-driven platform, Alivia 360. Operating as a SaaS provider, it delivers payment integrity and measurable financial recoveries for commercial and government payers.

Role Overview

The Payment Integrity Specialist directly audits payer claims across various business lines, identifying improper payments and quantifying recovered funds. This role empowers the individual to generate new audit approaches by recognizing data patterns, with comprehensive client-specific training provided on claims systems. Goal-oriented and detail-focused, the specialist maintains both quantitative targets and quality standards autonomously.

Key Responsibilities

• Audit claims from multiple payer lines (commercial, FEP, Medicaid, Medicare) to detect improper payments and recovery possibilities.
• Conduct thorough claims data analyses to identify root causes of payment errors and develop defensible audit findings.
• Achieve or surpass monthly financial identification goals assigned per client and audit type, including a ramp-up phase during onboarding.
• Ensure high accuracy in identified recoveries, minimizing false positives for client acceptance.
• Innovate at least one new audit concept monthly through pattern recognition in claims data.
• Deliver timely client audit results and comprehensive documentation supporting findings.
• Apply expertise in payment integrity and claims processing across multiple payer systems as client engagements evolve.
• Contribute to collective team knowledge by sharing trends, audit methods, and refining audit playbooks.

Qualifications

• Minimum of two years’ experience with payers or vendors specializing in payment integrity or auditing.
• Practical knowledge of claims processing and auditing for payment integrity.
• Broad exposure across different payer lines including commercial, FEP, Medicaid, and Medicare preferred.
• Strong analytical skills for diagnosing problems in complex data sets and pursuing root causes.
• Proficiency with Excel and adaptability to various claims software; client-specific system training is provided.
• History of meeting metric-driven, deadline-oriented goals while maintaining composure under performance expectations.
• High ethical standards and confidence in defending audit conclusions.
• Self-motivated and capable of managing workload with minimal supervision.
• Authorization to work in the U.S. and residency within the country, due to handling of personal health information.

Preferred Qualifications

• Specific experience in payment integrity auditing beyond general claims audit.
• Demonstrated ability to generate novel audit concepts and identify new recovery opportunities.

Additional Information

Council Capital emphasizes hiring diverse, high-performing talent who bring innovation, resilience, and dedication to making a meaningful impact in healthcare. The compensation offered for this role ranges from $75,000 to $80,000 annually.