Position: Payment Integrity SME Location: Remote 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
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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 $107.14/hr - $107.15/hr.
