Payment Integrity Program Development Senior Manager – Clinical & Facility Specialist

Accountabilities

• • Identify new payment integrity opportunities: Research clinical literature, specialty society guidelines, medical policies, and billing trends across inpatient, outpatient, ASC, and professional settings to uncover payment anomalies and develop original claim-edit concepts.
  • Design automated payment logic: Translate clinical documentation, coding frameworks, coverage policies, and billing regulations into detailed logic and parameters suitable for claims editing platforms.
  • Validate concepts with data: Analyze real-world claims and clinical data to test hypotheses, assess financial potential, refine rules, and establish parameters that minimize unnecessary provider friction.
  • Lead cross-functional policy development: Present original concepts to senior leaders and collaborate with Clinical Operations, Special Investigations, Claims, Legal, and other stakeholders to build alignment around new policies and rule architectures.
  • Own concepts from discovery to optimization: Manage the full lifecycle of payment integrity initiatives, including clinical research, selection criteria, logic testing, launch, post-launch refinement, and ongoing performance monitoring.
  • Apply expertise across care settings: Use strong clinical, coding, and facility billing knowledge to develop impactful solutions across complex inpatient and high-dollar claims as well as outpatient, ASC, and professional services.

  Requirements

  • Clinical and coding credentials: Active Registered Nurse (RN) license with direct inpatient clinical experience, such as ICU or Med-Surg, combined with an active professional coding certification such as CPC, CCS, CCS-P, or RHIA.
  • Payment integrity experience: At least 5 years of experience creating and authoring new payment integrity claim edits within a health plan or vendor environment, rather than primarily evaluating existing edit catalogs or implementing client-requested solutions.
  • Medicare and regulatory expertise: Strong knowledge of Medicare regulations, billing requirements, Local and National Coverage Determinations (LCDs/NCDs), and NCCI edit logic across multiple healthcare settings.
  • Multi-setting billing expertise: Deep understanding of inpatient MS-DRG/APR-DRG, outpatient and ASC APC/OPPS and fee schedules, as well as professional CPT/HCPCS coding and clinical guidelines.
  • Logic development experience: Hands-on experience writing detailed rules and structural specifications for commercial claims-editing engines or proprietary payer platforms.
  • Research and analytical skills: Ability to synthesize complex clinical and specialty guidelines into structured, actionable logic and interpret and validate data queries, with modern AI tools available to assist with SQL generation.
  • Executive communication and influence: Excellent storytelling, presentation, and stakeholder-management abilities, with demonstrated success building alignment around complex and original technical concepts.
  • Preferred: Experience applying Medicare rules and coverage determinations in a Medicare Advantage managed-care environment.
  • Preferred: Familiarity with AI workflows, large language models (LLMs), or automated pattern-matching technologies used to accelerate research, data analysis, and rule development.

  Benefits

  • Salary: $110,500–$150,000 per year, with the final offer determined by factors such as experience, qualifications, certifications, education, skills, and work location.
  • Employer-sponsored health, dental, and vision coverage, with low or no employee premiums.
  • Generous paid time off.
  • $100 monthly mobile or internet stipend.
  • Stock options for all employees.
  • Bonus eligibility for eligible roles below the Director level.
  • Parental leave program.
  • 401(k) program.
  • Remote work within the United States.
  • Additional benefits included as part of the overall total rewards package for full-time employees.