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Senior Consultant, Payment Integrity

3 hours, 7 minutes ago
United States
Full-time
Lead
Consultant
Operations
Agile Databricks Snowflake
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 11

Description

  • Lead client discovery sessions, workshops, executive presentations, and stakeholder engagements.
  • Serve as the internal payment integrity subject matter expert and trusted advisor to payer sponsors and risk panels.
  • Research market, industry, and regulatory trends, including federal, state, and ERISA compliance requirements.
  • Develop payment integrity strategies, policies, roadmaps, and contract recommendations aligned with client goals.
  • Create and maintain policies for external communication and lead cross-functional implementation efforts.
  • Partner with Product, Engineering, and Data/Analytics teams to improve payment integrity outputs and audit workflows.
  • Configure and validate payment integrity accelerators, including claim edits, authorization-to-claim matching, and billing-anomaly detection.
  • Apply client-specific policies and data within Snowflake or Databricks environments.
  • Translate payment integrity and claims-auditing judgment into claim-edit rules, review agents, and validation logic.

Requirements

  • 10+ years of experience in healthcare payment integrity, claims auditing, or reimbursement analysis, including 5+ years in consulting or advisory work.
  • Experience in payer or provider consulting, healthcare advisory, or an external payment integrity leadership role.
  • Deep hands-on knowledge of claims auditing, including Inpatient/DRG, outpatient modifiers, post-acute care, medical necessity, and specialty/high-cost drugs.
  • Strong consulting-style problem-solving, workshop facilitation, and recommendation development skills.
  • Experience developing and presenting payment integrity policies, strategies, and roadmaps to executive audiences.
  • Knowledge of reimbursement models, payer/provider operations, provider risk arrangements, and regulatory requirements.
  • Experience identifying and mitigating fraud, waste, and abuse, reviewing contracts, responding to audits, and handling escalated appeals.
  • Proven ability to lead client relationships and engagements, with willingness to travel to client sites as needed.
  • Preferred certifications include Six Sigma Black Belt, CPC, CCS, CFE, RHIA, or RHIT.
  • Preferred exposure to clinical claim editing, post-payment recovery, Special Investigations, Agile/lean development, AI automation, Snowflake, or Databricks.

Benefits

  • Base salary with 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 professional development environment.
  • Home office setup allowance.
  • Monthly cell phone allowance.

Interested in this position?

Apply directly on the company website

Apply Now

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