Complex Clinical Audit Business Solutions Lead
Core
Translates payment integrity audit knowledge into scalable product capabilities for pre-pay and post-pay programs, defining audit logic and partnering with engineering to build AI solutions.
Role type
Senior Product Lead (Payment Integrity)
Builds
Scalable product capabilities for DRG validation, clinical claim review, itemized bill review, claim editing, readmissions, and observation.
Domain
Healthcare / Payment Integrity / AI
Deliverable
production ML models | product features
Required skills
Payment integrity audit strategies, DRG validation, clinical claim review, itemized bill review, claim editing, readmissions, observation, audit logic definition, AI solution development, regulatory compliance, claims processing, adjudication systems, UB-04 data structures, ROI modeling, executive communication
Preferred skills
Generative AI, Large Language Models (LLMs), Natural Language Processing (NLP), prompt engineering, recovery workflows, eligibility verification, third-party liability, workers' compensation, fraud prevention, business requirements definition
Technologies
AI-enabled tools, LLMs, NLP
Responsibilities
Serve as primary operational subject matter expert for payment integrity methodologies, translate payer pain points and audit policy into product capabilities, define audit concepts and validation criteria, partner with engineering to build AI solutions, support roadmap prioritization and pilot launches
Seniority
Senior, hands-on IC