Payment Integrity Program Development Senior Manager – Clinical & Facility Specialist
Core
Architect and invent automated clinical claim edit and audit logic for inpatient, outpatient, ASC, and professional settings to ensure payment integrity.
Role type
Senior IC clinical payment integrity architect
Builds
Automated payment integrity logic and edit pipelines
Domain
Healthcare / Medical Billing & Claims
Deliverable
production ML models
Required skills
Active RN license, Active professional coding certification (CPC/CCS/CCS-P/RHIA), 5+ years net-new claim edit authoring, Medicare rules expertise, Multi-setting billing dynamics (MS-DRG/APR-DRG/APC/OPPP/CPT/HCPCS), Logic writing for claims engines, Data analysis (SQL)
Preferred skills
Medicare Advantage managed care experience, AI/LLM workflows for data analysis
Technologies
SQL, Claims editing engines (Optum/CES, Cotiviti, McKesson)
Responsibilities
Research clinical literature and guidelines to identify payment anomalies, Author end-to-end automated logic parameters, Validate hypotheses via data analysis, Pitch concepts to executive stakeholders, Lead multi-phased concept rollouts
Seniority
Senior, hands-on IC