Complex Clinical Audit Business Solutions Lead

About Us

Abacus Insights is transforming how data works for health plans. Our mission is simple: make healthcare data usable, so the people responsible for care and cost decisions can act faster, with confidence.

We help health plans break down data silos to create a single, trusted data foundation. That foundation powers better decisions—so plans can improve outcomes, reduce waste, and deliver better experiences for members and providers alike. Backed by $100M from top investors, we’re tackling big challenges in an industry that’s ready for change. Our platform enables GenAI use cases by delivering clean, connected, and reliable healthcare data to support automation, prioritization, and decision workflows—and it’s why we are leading the way.

Our innovation begins with people. We are bold, curious, and collaborative—because the best ideas come from working together. We embrace the thoughtful use of AI and automation to drive innovation and efficiency, and we look for individuals who are curious and adaptable—those excited to leverage emerging technologies to enhance how we work—while keeping human insight, connection, and our clients at the center of every decision.

Ready to make an impact? Join us and let’s build the future together.

About the Role

The Complex Clinical Audit Business Solutions Lead is a clinical, operational, and product-facing expert who translates payment integrity audit knowledge into scalable product capabilities. This role supports pre-pay and post-pay programs (Complex Clinical Audit), including DRG validation, clinical claim review, itemized bill review, claim editing, readmissions, and observation.

The Business Solutions Lead, Payment Integrity, partners with product, engineering, AI Engineering, clinical, operations, customer success, and payer stakeholders to define audit logic, identify savings opportunities, reduce provider abrasion, and improve product accuracy and defensibility.

Your day to day

• Serve as the primary operational 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 priority PI domains.
• Partner with engineering to define, develop, and build high-performing, scalable, trustworthy, reliable, and accurate AI solutions.
• Support roadmap prioritization, pilot launches, outcome reviews, positioning, and customer expansion.

What you bring to the team

• 5–10+ years of progressive experience in Payment Integrity, healthcare audit, clinical operations, or healthcare technology product management.
• 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 impact payment integrity program design and execution.
• 3+ years in a PI-domain leadership role, such as audit operations, PI program management, vendor product management, or payer PI strategy.
• Strong working knowledge across multiple PI domains, including DRG audit, clinical validation, IBR, edit-based audits, observation, readmissions, COB, SIU, and UM adjacencies.
• Experience translating audit operations, clinical conte