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Complex Clinical Audit Business Solutions Lead

21 hours, 7 minutes ago
United States
Full-time
Senior
Product Manager
Product Management
Generative AI LLM NLP
Apply Now
Abacus Insights

Abacus Insights

Abacus Insights simplifies healthcare data with intelligent solutions, unlocking data value and empowering health plans, consumers, and providers.

Insurance
51-250
Founded 2017
$82M raised
View All Jobs 4

Description

  • Serve as the primary subject matter expert for payment integrity methodologies, audit programs, and product requirements.
  • Translate payer pain points, contract language, audit policy, and operational workflows into product capabilities.
  • Define audit concepts, savings opportunities, validation criteria, and defensibility standards across key payment integrity domains.
  • Partner with product, engineering, AI Engineering, clinical, operations, customer success, and payer stakeholders to shape solutions.
  • Work with engineering to define, develop, and build scalable, trustworthy, reliable, and accurate AI solutions.
  • Support roadmap prioritization, pilot launches, outcome reviews, positioning, and customer expansion.
  • Create prototypes and visualize workflows using internal AI-enabled tools to communicate product vision and business value.
  • Help identify opportunities to improve savings identification, recovery outcomes, product accuracy, and provider experience.

Requirements

  • 5–10+ years of progressive experience in Payment Integrity, healthcare audit, clinical operations, or healthcare technology product management.
  • 3+ years in a PI-domain leadership role such as audit operations, PI program management, vendor product management, or payer PI strategy.
  • Deep knowledge of U.S. healthcare payer payment integrity programs, including pre-pay and post-pay audit strategies, vendor management, savings methodologies, recovery operations, and performance measurement.
  • Understanding of payer regulatory, compliance, and audit considerations that affect payment integrity program design and execution.
  • Strong working knowledge of multiple PI domains, including DRG audit, clinical validation, IBR, edit-based audits, observation, readmissions, COB, SIU, and UM adjacencies.
  • Experience translating audit operations, clinical content, and payer requirements into software workflows, analytics, or product requirements.
  • Strong analytical and communication skills, with comfort using hit-rate analysis, ROI modeling, outcome measurement, and executive-ready narratives.
  • Familiarity with claims processing, adjudication systems, provider billing, UB-04 data structures, and healthcare interoperability standards.
  • Experience partnering with Product Management, Engineering, Data Science, AI Engineering, or Clinical Informatics teams to build software solutions (preferred).
  • Familiarity with Generative AI, LLMs, NLP, prompt engineering, or healthcare AI applications (preferred).
  • Experience defining business requirements, user stories, acceptance criteria, and product specifications (preferred).

Benefits

  • Base salary plus eligibility for performance bonuses and equity grants.
  • Unlimited paid time off.
  • Work from anywhere flexibility.
  • Comprehensive health coverage with multiple plan options.
  • Equity for every employee.
  • Growth-focused environment with support for professional development.
  • Home office setup allowance.
  • Monthly cell phone allowance.

Interested in this position?

Apply directly on the company website

Apply Now

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