Lead, Medical Network Claims Pricer

The posting, as Judi Health wrote it

About Judi Health

Judi Health is a health technology company providing benefit administration solutions to employers, unions, health plans, and government entities. Judi Health replaces fragmented, outdated systems with the industry's first Unified Claims Processing™ architecture, seamlessly consolidating pharmacy and medical benefit administration on a single, secure platform. By delivering true price transparency, eliminating unnecessary middleman fees, and leveraging advanced AI-powered care delivery, Judi Health helps clients achieve unprecedented operational efficiency and service levels.

At Judi Health, we're deploying the infrastructure our country needs to deliver the healthcare we all deserve. We are the intelligence platform powering benefits plans for millions of Americans and proudly leading the next generation of care. To learn more, visit www.judi.health .

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 met

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mpliance, 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.

New York, NY Salary Range
$128,000 — $160,000 USD

Denver, CO Salary Range
$117,600 — $147,600 USD

Charlotte, NC Salary Range
$106,800 — $133,500 USD

All employees are responsible for adherence to the Judi Health Code of Conduct including the reporting of non-compliance. This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

We provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

By submitting an application, you agree to the retention of your personal data for consideration for a future position at Judi Health. More details about Judi Health's privacy practices can be found at https://www.judi.health/legal/privacy-policy .