Payment Integrity SME

Our client, an IT Services and Consulting company, is looking for a Payment Integrity SME for their Remote location.
 
Responsibilities:

• Define business and functional requirements for payment integrity product capabilities (edit libraries, clinical/coding validation, FWA-adjacent overpayment detection)
• Translate payer operational pain points into product roadmap input
• Validate accuracy and defensibility of edits/logic against CMS, state, and commercial payment policy
• Support client engagements: current-state assessments, savings opportunity sizing, RFP/proposal content
• Partner with data science/engineering teams to ensure models and rules reflect real adjudication scenarios
• Represent the SME voice in client-facing demos, workshops, and sales support
• Payment policy fluency (CMS NCCI, LCD/NCD, state Medicaid, commercial)
• Claims adjudication lifecycle end-to-end
• Ability to operate at both strategic (roadmap, positioning) and operational (edit-level, workflow-level) altitude
• Comfortable engaging with payer client stakeholders directly

• Seasoned subject matter expert to guide the design, validation, and go-to-market positioning of payment integrity capabilities and products for health plan clients.
• Bridges deep payer operational knowledge with product/technology teams building pre-pay and post-pay solutions.
• 10+ years in healthcare payer operations, with direct experience in claims payment integrity (pre-pay editing, post-pay recovery, COB, subrogation, overpayment identification)
• Prior experience at a health plan, BPO, or payment integrity vendor (e.g., Optum, Cotiviti, HMS/Gainwell, Change Healthcare) preferred
• Track record contributing to the design or configuration of payment integrity products/platforms — not just using them
• Working knowledge of core claims platforms (QNXT, Facets, or similar) and how PI logic integrates with adjudication workflows
• Years of experience:   5.00 Years of Experience

• Health Benefits
• Referral Program
• Excellent growth and advancement opportunities