Abacus Insights - Complex Clinical Audit Business Solutions Lead

• 5–10+ years of progressive experience in Payment Integrity, healthcare audit, clinical operations, or healthcare technology product management. • 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. • Understanding of payer regulatory, compliance, and audit considerations that impact payment integrity program design and execution. • 3+ years in a PI-domain leadership role, such as audit operations, PI program management, vendor product management, or payer PI strategy. • Strong working knowledge across multiple PI domains, including DRG audit, clinical validation, IBR, edit-based audits, observation, readmissions, COB, SIU, and UM adjacencies. • 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. • Utilize internal AI-enabled tools to quickly create prototypes, visualize workflows, and showcase product functionality, enabling effective communication of product vision and business value. • Champion the use of internal AI tools to accelerate ideation, solution design, and demonstration of product capabilities, helping stakeholders understand requirements, opportunities, and proposed outcomes. • What we would like to see, but not required • 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. • Compensation: Compensation for this role is based on experience, skills, and location, and includes base salary plus eligibility for performance bonuses and equity grants.