Senior Consultant, Payment Integrity

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

📋 Description

• Take ownership of workstreams on client projects from initial scoping and hypothesis formulation through to analysis, recommendations, and execution.

• Facilitate client discovery meetings, workshops, steering committee updates, and executive presentations.

• Identify challenges, deliver data-supported recommendations, and secure endorsement from executives and payer stakeholders.

• Act as Abacus’ internal expert and trusted consultant on payment integrity strategy, claims accuracy, and policy matters.

• Explore market, industry, and regulatory trends related to payment integrity.

• Evaluate compliance with federal, state, and ERISA regulations.

• Analyze contracts and develop customized payment integrity strategies, policies, and implementation plans.

• Develop and maintain payment integrity policies for external communication purposes.

• Guide cross-functional teams through the implementation process.

• Oversee client relationships and expectations, including project scope, timelines, risks, and value delivery.

• Provide insights from clients and the market to Product, Engineering, and Data/Analytics teams.

• Utilize interoperability standards to enhance audit and record-retrieval processes.

• Set up and validate Payment Integrity accelerators within client Snowflake or Databricks environments.

• Contribute to consulting methodologies, reusable frameworks, accelerators, and thought leadership initiatives.

⛳️ Requirements

• Previous consulting experience at a prestigious global firm or a leading healthcare-focused advisory organization.

• Generally, 5+ years of consulting experience, particularly in client-facing roles within a healthcare payer practice, ideally focused on payment integrity, claims, or reimbursement.

• Over 10 years of overall experience in healthcare payment integrity, claims auditing, or reimbursement analysis.

• Experience across clinical, operational, and data domains.

• Strong hypothesis-driven problem-solving skills, structured analytical approach, executive-ready storytelling, and workstream management capabilities.

• Extensive hands-on knowledge of claims auditing workflows and various claim types, including Inpatient/DRG validation, Outpatient modifiers, Post-Acute Care, Medical Necessity, and Specialty/High Cost Drugs.

• Experience in developing, drafting, and presenting payment integrity policies, strategies, and roadmaps.

• Comprehensive understanding of reimbursement models, payer/provider operations, and regulatory factors.

• Familiarity with provider risk arrangements, including delegated risk, capitation, and risk panels.

• Working knowledge of federal, state, and ERISA regulations.

• Experience in identifying and addressing fraud, waste, and abuse.

• Background in reviewing contracts for compliance and managing audits and escalated appeals.

• Demonstrated ability to lead client relationships and engagements, including discovery sessions, workshops, and executive presentations.

• Willingness to travel to client sites as necessary.

• Excellent communication skills and a polished executive presence.

• Bachelor’s degree is required.

🏝️ Benefits

• Unlimited paid time off.

• Flexibility to work from any location.

• Extensive health coverage with various plan options.

• Equity available for every employee.

• Environment focused on growth and professional development opportunities.

• Home office setup allowance provided.

• Monthly cell phone allowance.

• Eligibility for performance bonuses.

• Equity grants offered.