State Licensed Clinical Payment Integrity Manager

Job Summary

As the Senior Payment Integrity Program Development Manager, this full-time remote position will manage the development of clinical claim edit and audit processes, conducting independent research and analysis to create innovative payment integrity logic across various healthcare settings.

Key responsibilities

• Drive ground-up innovation by researching clinical literature and billing trends to identify payment anomalies and formulate original edit hypotheses
• Author end-to-end logic from scratch, translating clinical documentation and coding frameworks into automated logic parameters
• Lead multi-phased concept rollouts, from clinical discovery to post-launch performance tracking, while collaborating with cross-functional teams

Required qualifications

• Active Registered Nurse (RN) license with direct inpatient clinical experience and a professional coding certification (e.g., CPC, CCS)
• 5+ years of experience in payment integrity, specifically as the primary author of new claim edits within a health plan or vendor setting
• Expert understanding of Medicare rules, billing regulations, and NCCI edit logic across various care settings
• Deep knowledge of facility and professional billing dynamics, including inpatient and outpatient coding guidelines
• Direct experience authoring detailed rules for implementation in commercial claims editing engines or proprietary platforms