Payment Integrity Program Development Senior Manager – Clinical & Facility Specialist

For our client, we are seeking a Payment Integrity Program Development Senior Manager – Clinical & Facility Specialist to join the team of a leader in the Hospitals & Medical Centers space.

This role will focus on developing new payment integrity concepts that improve accuracy, strengthen claims review processes, and support sound reimbursement practices. The person in this position will partner closely with clinical, coding, analytics, and operational stakeholders to turn complex medical policy ideas into scalable edit logic. Success in this role will require deep clinical and claims expertise, along with the ability to evaluate financial impact and build alignment around new program concepts.

The ideal candidate will bring a strong blend of inpatient clinical knowledge, coding expertise, and payment integrity experience to help shape and launch new initiatives in a highly regulated healthcare environment.

Location: Remote - US based candidates only, no visa sponsorship available

Compensation: $110,500 – $150,000 annually

Responsibilities

• Drive concept development by researching clinical literature and identifying potential payment anomalies
• Create automated payment integrity logic from clinical documentation and coding frameworks
• Analyze data to validate clinical hypotheses and assess financial viability in real-world datasets
• Lead cross-functional discussions to build consensus around policy interpretations and edit logic
• Manage multi-phase concept rollouts from discovery through performance tracking

Qualifications

• Active Registered Nurse (RN) license with inpatient clinical experience, such as ICU or Med-Surg, and a professional coding certification such as CPC, CCS, CCS-P, or RHIA
• More than 5 years of experience in payment integrity as a primary author of new claims edits within a health plan or vendor environment
• Strong knowledge of Medicare rules, billing regulations, and Local/National Coverage Determinations (LCDs/NCDs)
• Experience with inpatient and outpatient billing dynamics, including MS-DRG/APR-DRG and APC/OPPS guidelines
• Demonstrated ability to author rules and logic specifications for commercial claims editing engines
• Strong skills in researching and interpreting complex clinical guidelines, as well as validating data queries
• Proven ability to build cross-functional alignment around complex technical concepts

Benefits

• Employer-sponsored health, dental, and vision plans with low or no premium
• Generous paid time off policies
• Monthly stipend for mobile or internet expenses
• Stock options available to all employees
• Bonus and commission eligibility for eligible roles
• Comprehensive parental leave program
• Participation in a 401K plan

Our client is an equal opportunity employer. We encourage you to apply even if you don’t meet every qualification—your background could be exactly what this team needs.