Abacus Insights - Director, Payment Integrity Business Solutions – Claim Auditing

• 10+ years of hands-on experience at a payer or payer vendor in a product or operational role with focus on complex claims auditing • Deep, hands-on knowledge of end-to-end complex claims auditing workflows • Clinical training or active coding certification • Expertise in one or more of the following complex claim types: Inpatient (DRG validation), Outpatient (modifiers), Post-Acute Care, Medical Necessity, Specialty/High Cost Drugs • Knowledge of payer-side data systems (claims adjudication platforms, audit automation engines, care management systems) • Familiarity with audit-relevant regulatory frameworks: CMS guidelines, Medicare/Medicaid audit requirements, RAC/MAC/OIG standards • Ability to translate complex clinical and operational requirements into clear product and technical specifications for non-clinical stakeholders • Demonstrated ability to engage, consult, and build trust with payer clients at the operational and leadership levels • What We Would Love to See, but Not Required • Exposure to adjacent payment integrity disciplines including clinical claim editing, post-payment recovery, fraud/waste/abuse (FWA) detection, and Special Investigations • Exposure to Agile or lean product development environments • What you’ll get in return • Unlimited paid time off – recharge when you need it • Work from anywhere – flexibility to fit your life • Comprehensive health coverage – multiple plan options to choose from • Equity for every employee – share in our success • Growth-focused environment – your development matters here • Monthly cell phone allowance – stay connected with ease #LISB1 #LI-Remote