AI-Driven Payment Integrity Lead (Complex Claims)

Abacus Insights; United States; On-site; USD 150,000 - 210,000; Full time

Benefits offered by this job

Unlimited paid time off

Work from anywhere

Comprehensive health coverage

Equity for every employee

Growth-focused environment

Home office setup allowance

Monthly cell phone allowance

Job summary

Abacus Insights seeks a Payment Integrity Business Solutions Lead to translate audit knowledge into scalable product capabilities. You will work across clinical, operational, and product teams to define audit logic, identify savings opportunities, and improve product accuracy and defensibility.

Join a cross-functional team partnering with product, engineering, data science, and payer stakeholders to drive complex claims initiatives, DRG validation, and post-pay program success while advancing

Qualifications

• 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.
• 3+ years in a PI-domain leadership role with cross-domain collaboration.
• Experience translating audit operations and payer requirements into software workflows and product requirements.
• Strong analytical and communication skills, ROI modeling, and executive-ready narratives.
• Familiarity with claims processing, UB-04 data structures, and interoperability standards.
• Experience utilizing AI-enabled tools to prototype workflows and demonstrate product capabilities.

Responsibilities

• Serve as the primary operational SME for payment integrity methodologies, audit programs, and product requirements.
• Translate payer pain points and contract language into product capabilities.
• Define audit concepts, savings opportunities, validation criteria, and defensibility standards.
• Partner with engineering to build scalable, reliable AI solutions for payment integrity.
• Support roadmap prioritization, pilots, outcomes, and customer expansion.

Skills

Payment Integrity

Healthcare audit

Product management

Leadership

Data analysis

Stakeholder communication

ROI modeling

AI prototyping

Tools

UB-04 data structures

Claims processing systems

Interoperability standards

AI tools experienced

Job description

Abacus Insights seeks a Payment Integrity Business Solutions Lead to translate audit knowledge into scalable product capabilities. You will work across clinical, operational, and product teams to define audit logic, identify savings opportunities, and improve product accuracy and defensibility.

Join a cross-functional team partnering with product, engineering, data science, and payer stakeholders to drive complex claims initiatives, DRG validation, and post-pay program success while advancing