Senior Manager, Payment Integrity Program Development – Clinical & Facility Specialist

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

📋 Description

• Conduct research on clinical literature, guidelines from specialty societies, and billing trends across multiple settings to pinpoint payment discrepancies and develop original edit hypotheses.

• Create comprehensive automated payment integrity logic from the ground up.

• Convert clinical documentation, medical policies, and coding frameworks for facilities and professionals into accurate logic parameters.

• Utilize advanced AI tools for data analysis and SQL query generation to test hypotheses and confirm financial viability.

• Establish parameters that minimize provider abrasion.

• Present innovative clinical concepts to directors and executive stakeholders.

• Foster agreement among Clinical Operations, SIU, Claims, and Legal regarding policy interpretations and rule frameworks.

• Oversee the rollout of concepts from clinical discovery through criteria selection, logic testing, post-launch adjustments, and ongoing performance monitoring.

• Leverage clinical expertise across inpatient, outpatient, Ambulatory Surgical Center, and professional environments.

⛳️ Requirements

• A valid Registered Nurse (RN) license with direct clinical experience in inpatient settings (e.g., ICU, Med-Surg).

• A current professional coding certification (e.g., CPC, CCS, CCS-P, or RHIA).

• Over 5 years of experience in payment integrity, having been the main author and creator of new claim edits in a health plan or vendor environment.

• In-depth knowledge of fundamental Medicare regulations, billing rules, Local/National Coverage Determinations (LCDs/NCDs), and NCCI edit logic across various care settings.

• Extensive understanding of facility and professional billing processes, including inpatient (MS-DRG/APR-DRG), outpatient/ASC (APC/OPPS, fee schedules), and professional CPT/HCPCS clinical guidelines.

• Direct experience in authoring detailed rules and structural logic specifications for integration into commercial claims editing engines (e.g., Optum/CES, Cotiviti, McKesson) or proprietary/internal payer rules platforms.

• Demonstrated capability to distill complex clinical specialty guidelines into structured logic.

• Proficiency in reading, interpreting, and validating data queries (SQL support provided via advanced AI tools).

• Outstanding narrative and framing abilities with a proven history of fostering cross-functional alignment around intricate, original technical concepts.

• Specialized experience implementing rules and coverage determinations specifically within a Medicare Advantage (MA) managed care setting.

• Familiarity with utilizing AI workflows, large language models (LLMs), or automated pattern-matching tools to expedite data analysis, literature reviews, and rule development.

🏝️ Benefits

• Employer-sponsored health, dental, and vision plans with low or no premiums.

• Generous paid time off.

• $100 monthly stipend for mobile or internet expenses.

• Stock options available for all employees.

• Bonus eligibility for all positions except Director and above.

• Commission eligibility for Sales roles.

• Parental leave program.

• 401K program.