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Director, Payment Integrity Business Solutions – Claim Auditing

1 hour, 50 minutes ago
United States
Full-time
Lead
Product Manager
Product Management
Agile Generative AI
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 6

Description

  • Serve as the internal and external subject matter expert for end-to-end claims auditing workflows, including pre-pay and post-pay audit processes.
  • Partner with Product, Engineering, and AI teams to translate auditing workflows into intelligent, AI-powered solution requirements.
  • Act as a client-facing expert in sales and delivery meetings, product demos, discovery sessions, and client support.
  • Identify gaps between current product capabilities and real-world auditing needs and champion the roadmap to close them.
  • Represent the complex case review audit team in cross-functional product discussions to ensure clinical accuracy and operational practicality.
  • Partner with product and growth marketing on sales enablement, growth marketing initiatives, thought leadership, and go-to-market execution.

Requirements

  • 10+ years of hands-on experience at a payer or payer vendor in a product or operational role focused on complex claims auditing.
  • Deep, hands-on knowledge of end-to-end complex claims auditing workflows.
  • Clinical training or an active coding certification.
  • Expertise in one or more complex claim types: Inpatient (DRG validation), Outpatient (modifiers), Post-Acute Care, Medical Necessity, or Specialty/High Cost Drugs.
  • Knowledge of payer-side data systems, including claims adjudication platforms, audit automation engines, and care management systems.
  • Familiarity with audit-relevant regulatory frameworks such as CMS guidelines, Medicare/Medicaid audit requirements, and RAC/MAC/OIG standards.
  • Ability to translate complex clinical and operational requirements into clear product and technical specifications for non-clinical stakeholders.
  • Demonstrated ability to engage, consult, and build trust with payer clients at both operational and leadership levels.
  • Exposure to adjacent payment integrity disciplines such as clinical claim editing, post-payment recovery, fraud/waste/abuse detection, and Special Investigations (preferred).
  • Exposure to Agile or lean product development environments (preferred).

Benefits

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

Interested in this position?

Apply directly on the company website

Apply Now

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