Job description

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

Requirements:

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

Why Should You Apply?

Payment Integrity SME

Role overview