Complex Clinical Audit Business Solutions Lead

Payment Integrity lives at the intersection of clinical nuance and product logic — and the Complex Clinical Audit (CCA) Business Solutions Lead is where that intersection gets built. This is not a clinical license role — it's a deep payment integrity SME role for someone who has spent 5+ years embedded in payment integrity on the payer or vendor side of U.S. healthcare, and who understands how to turn that domain knowledge into the technical backbone of a product.

You'll translate coding guidelines, MS-DRG definitions, and payer audit policy into workable product logic — building the prompts, connectors, and workflows that let us validate claims against medical records at scale. You'll work hands-on with AI Engineering on the backend build, developing test scenarios and validation criteria for new audit capabilities, and you'll be the person in the room with clients: demoing what we've built, explaining our data foundation, and showing payers how we solve their pain points across the payment integrity landscape.

This role sits at the center of a fast-growing product suite — starting in Complex Clinical Audit and expanding into itemized bill review and beyond — and you'll need to understand not just CCA but how it connects to the rest of payment integrity: COB, SIU, and fraud/waste investigation. If you've lived in the payer or vendor side of PI, know your way around a UB-04 and stop-loss reimbursement, and want to help build the product rather than just operate it, this is your seat at the table.

NOTE: This is a remote role with US working hours (Eastern time zone)

• Serve as the primary operational SME for payment integrity methodologies, audit programs, and product requirements across Complex Clinical Audit.
• Translate coding clinic guidelines, MS-DRG definitions, payer contract language, and audit policy into product capabilities and workable prompts against medical records.
• Partner directly with AI Engineering to build connectors, prompts, and load-UI workflows — working in a “shift-left” model with AI doing the heavy lifting and a human in the loop.
• Develop test scenarios and validation criteria for new audit capabilities and AI features.
• Demo product capabilities directly to clients at major U.S. payer organizations, explaining data foundation, audit logic, and how we solve their PI pain points.
• Define savings opportunities, validation criteria, and defensibility standards across priority PI domains.
• Understand and apply deep knowledge of UB-04 structures, itemized bills, and stop-loss reimbursement and how each affects DRG weighting.
• Support roadmap prioritization, pilot launches, outcome reviews, positioning, and customer expansion conversations.

• 5+ years embedded in payment integrity on the payer or vendor side of U.S. healthcare — this is not a clinical license requirement, but deep, hands-on PI domain fluency is essential.
• Experience building technical PI solutions: backend data engineering workflows, EMR/connector builds, or load-UI systems that get claims processing right.
• Deep knowledge of U.S. healthcare payer payment integrity programs, including pre-pay and post-pay audit strategies, vendor management, savings methodologies, recovery operations, and performance measurement.
• Strong working knowledge across multiple PI domains — DRG audit, clinical validation, IBR, edit-based audits, observation, readmissions — and how they connect to COB, SIU, and FWA.
• Comfort being client-facing: demoing product, presenting to U.S. payer stakeholders, and holding your own in an executive-level conversation (this role works U.S. Eastern hours and is regularly in front of clients).
• Experience translating audit operations, clinical content, and payer requirements into software workflows, analytics, or product requirements.
• Strong analytical and communication skills, with comfort using hit-rate analysis, ROI modeling, outcome measurement, and executive-ready narratives.
• Familiarity with claims processing, adjudication systems, provider billing, UB-04 data structures, and healthcare interoperability standards.
• Comfort using internal AI-enabled tools to quickly prototype, visualize workflows, and showcase product functionality to communicate product vision and business value.
• A track record of championing AI tools to accelerate ideation, solution design, and demonstration of product capabilities for stakeholders.

• Experience partnering directly with Product Management, Engineering, Data Science, AI Engineering, or Clinical Informatics teams to build software solutions.
• Familiarity with Generative AI, Large Language Models (LLMs), Natural Language Processing (NLP), prompt engineering, or healthcare AI applications.
• Understanding of recovery workflows, eligibility verification, accident-related claims, third-party liability, workers’ compensation, and other payment responsibility determinations.
• Familiarity with FWA investigation methods, claim anomaly detection, provider billing patterns, and healthcare fraud prevention programs.
• Experience identifying opportunities to integrate COB, subrogation, FWA, and payment integrity data to improve savings identification and recovery outcomes.
• Experience defining business requirements, user stories, acceptance criteria, and product specifications

• Competitive Leave & Benefits
• Comprehensive health coverage
• Equity for every employee – share in our success
• Growth-focused environment – your development matters here