Complex Clinical Audit Business Solutions Lead

Responsibilities: Translate clinical coding guidelines and payer audit policies into technical product logic and AI-driven workflows. Partner with AI Engineering to build audit capabilities and demo these solutions directly to major U.S. payer organizations.

Requirements: Requires 5+ years of deep payment integrity experience on the payer or vendor side of U.S. healthcare. Must have a strong ability to translate audit operations into software requirements and be comfortable in client-facing executive roles.

Key skills: Payment Integrity, Complex Clinical Audit, MS-DRG Definitions, UB-04 Data Structures, AI Prompt Engineering, Client Demoing, Claims Processing, Healthcare Interoperability, ROI Modeling, Audit Policy Translation, Vendor Management, Recovery Operations

Keywords: Payment Integrity, Complex Clinical Audit, MS-DRG, UB-04, Generative AI, LLM, NLP, Prompt Engineering, Healthcare Data, Payer Audit, Clinical Validation, Itemized Bill Review, COB, SIU, FWA, Claims Adjudication, Stop-loss Reimbursement, EMR Connectors, Healthcare Interoperability, ROI Modeling, Hit-rate Analysis, Product Logic, Data Engineering, Clinical Informatics