Payment Integrity SME

Spectraforce; United States; On-site; USD 165,000 - 193,000; Part time

Job summary

Spectraforce is seeking a seasoned subject matter expert to guide the design, validation, and go-to-market positioning of payment integrity capabilities for health plan clients. The role bridges payer operations with product and technology teams delivering pre-pay and post-pay solutions.

Responsibilities include defining requirements for edits and validation against CMS and state policies, translating payer pain points into roadmap input, and supporting client engagements through assessments and

Qualifications

• 10+ years in healthcare payer operations, with direct experience in claims payment integrity (pre-pay editing, post-pay recovery, COB, subrogation, overpayment identification)
• Experience at a health plan, BPO, or payment integrity vendor preferred
• Track record designing or configuring PI products/platforms, not just usage
• Knowledge of core claims platforms and how PI logic integrates with adjudication workflows

Responsibilities

• Define business and functional requirements for payment integrity product capabilities (edit libraries, validation)
• Translate payer pain points into product roadmap input
• Validate edits against CMS/state/commercial payment policy
• Support client engagements: assessments, savings opportunity sizing, proposals
• Collaborate with data science/engineering to reflect real adjudication scenarios
• Represent SME in client demos, workshops, and sales support
• Understand CMS NCCI, LCD/NCD, Medicaid, and commercial policies
• Oversee claims adjudication lifecycle end-to-end
• Balance strategic roadmap with operational edit/workflow details
• Engage with payer client stakeholders directly

Skills

Payer operations expertise

Payment integrity

Product/PM input

Client engagement

Tools

QNXT

Facets

Job description

Duration: 3 Months (performance-based extension to 6 months)

Job Description:

Seasoned subject matter expert to guide the design, validation, and go-to-market positioning of payment integrity capabilities and products for health plan clients. Bridges deep payer operational knowledge with product/technology teams building pre-pay and post-pay solutions.

Responsibilities:

• Define business and functional requirements for payment integrity product capabilities (edit libraries, clinical/coding validation, FWA-adjacent overpayment detection)
• Translate payer operational pain points into product roadmap input
• Validate accuracy and defensibility of edits/logic against CMS, state, and commercial payment policy
• Support client engagements: current-state assessments, savings opportunity sizing, RFP/proposal content
• Partner with data science/engineering teams to ensure models and rules reflect real adjudication scenarios
• Represent the SME voice in client-facing demos, workshops, and sales support
• Payment policy fluency (CMS NCCI, LCD/NCD, state Medicaid, commercial)
• Claims adjudication lifecycle end-to-end
• Ability to operate at both strategic (roadmap, positioning) and operational (edit-level, workflow-level) altitude
• Comfortable engaging with payer client stakeholders directly

Required:

• 10+ years in healthcare payer operations, with direct experience in claims payment integrity (pre-pay editing, post-pay recovery, COB, subrogation, overpayment identification)
• Prior experience at a health plan, BPO, or payment integrity vendor (e.g., Optum, Cotiviti, HMS/Gainwell, Change Healthcare) preferred
• Track record contributing to the design or configuration of payment integrity products/platforms — not just using them
• Working knowledge of core claims platforms (QNXT, Facets, or similar) and how PI logic integrates with adjudication workflows

Years of Experience: 15 Years of Experience

At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position's pay range is $120.00/hr - $140.00/hr.