Payment Integrity Product Development Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Act as the primary expert in Skilled Nursing Facility (SNF) for the product development team by converting regulatory and clinical requirements into audit rules, workflows, and operational processes.

• Assess and enhance the SNF audit methodology, including criteria for medical necessity, standards for documentation, and requirements for coding.

• Establish the scope of Minimum Viable Product (MVP), plan roadmap advancements, and ensure readiness for implementation.

• Utilize extensive knowledge of CMS SNF regulations, Patient-Driven Payment Model (PDPM), Minimum Data Set/Resident Assessment Instrument (MDS/RAI), therapy documentation, and state Medicaid policies.

• Keep track of regulatory updates and suggest necessary product modifications.

• Determine and validate the logic for claim selection, risk indicators, and scoring models.

• Create and validate comprehensive workflows, encompassing intake, clinical review, provider outreach, and appeals processes.

• Set expectations for Service Level Agreements (SLA) regarding turnaround times, provider response periods, and internal review cycles.

• Assist in training clinical reviewers, auditors, and provider engagement teams.

• Specify reporting requirements for audit outcomes, savings, provider trends, and operational Key Performance Indicators (KPIs).

• Collaborate with analytics to ensure the accuracy and functionality of dashboards and reporting tools.

• Identify areas for continuous improvement based on findings from audits.

• Serve as a Subject Matter Expert (SME) during product implementation, ensuring all elements are prepared for deployment.

⛳️ Requirements

• 5-10+ years of experience in Skilled Nursing Facility clinical operations, utilization management, payment integrity, or audit programs.

• Solid understanding of CMS SNF regulations, PDPM, MDS/RAI, therapy documentation, and criteria for medical necessity.

• Experience in developing or implementing clinical audit programs for Medicaid, Medicare, and/or commercial payors.

• Familiarity with claims data, coding standards, and documentation requirements.

• Ability to translate intricate clinical and regulatory concepts into precise operational and product specifications.

• Excellent communication, analytical, and data comprehension skills.

• Preferred qualifications include licensure as an RN, PT, OT, SLP, or other clinical credentials.

• Experience with payment integrity vendors, health plans, or state Medicaid agencies.

• Background in product development or clinical audit solution design.

• Experience in developing claims scoring models or collaborating with analytics teams.

🏝️ Benefits

• Comprehensive health, dental, and vision insurance.

• Competitive salary and performance bonuses.

• Opportunities for professional development and continuing education.

• Flexible work schedules and remote work options.

• Supportive and collaborative work environment.