Complex Clinical Audit Business Solutions Lead

The Complex Clinical Audit Business Solutions Lead is a clinical, operational, and product-facing expert who translates payment integrity audit knowledge into scalable product capabilities. This role supports pre-pay and post-pay programs (Complex Clinical Audit), including DRG validation, clinical claim review, itemized bill review, claim editing, readmissions, and observation.

The Business Solutions Lead, Payment Integrity, partners with product, engineering, AI Engineering, clinical, operations, customer success, and payer stakeholders to define audit logic, identify savings opportunities, reduce provider abrasion, and improve product accuracy and defensibility.

• Serve as the primary operational subject matter expert for payment integrity methodologies, audit programs, and product requirements.
• Translate payer pain points, contract language, audit policy, and operational workflows into product capabilities.
• Define audit concepts, savings opportunities, validation criteria, and defensibility standards across priority PI domains.
• Partner with engineering to define, develop, and build high-performing, scalable, trustworthy, reliable, and accurate AI solutions.
• Support roadmap prioritization, pilot launches, outcome reviews, positioning, and customer expansion.

• 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, vendor management, savings methodologies, recovery operations, and performance measurement.
• Understanding of payer regulatory, compliance, and audit considerations that impact payment integrity program design and execution.
• 3+ years in a PI-domain leadership role, such as audit operations, PI program management, vendor product management, or payer PI strategy.
• Strong working knowledge across multiple PI domains, including DRG audit, clinical validation, IBR, edit-based audits, observation, readmissions, COB, SIU, and UM adjacencies.
• Experience translating audit operations, clinical content, and payer requirements into software workflows, analytics, or product requirements.
• Strong analytical and communication skills, with comfort using hit-rate analysis, ROI modeling, outcome measurement, and executive-ready narratives.
• Familiarity with claims processing, adjudication systems, provider billing, UB-04 data structures, and healthcare interoperability standards.
• Utilize internal AI-enabled tools to quickly create prototypes, visualize workflows, and showcase product functionality, enabling effective communication of product vision and business value.
• Champion the use of internal AI tools to accelerate ideation, solution design, and demonstration of product capabilities, helping stakeholders understand requirements, opportunities, and proposed outcomes.

• Experience partnering directly with Product Management, Engineering, Data Science, AI Engineering, or Clinical Informatics teams to build software solutions.
• Familiarity with Generative AI, Large Language Models (LLMs), Natural Language Processing (NLP), prompt engineering, or healthcare AI applications.
• Understanding of recovery workflows, eligibility verification, accident-related claims, third-party liability, workers’ compensation, and other payment responsibility determinations.
• Familiarity with FWA investigation methods, claim anomaly detection, provider billing patterns, and healthcare fraud prevention programs.
• Experience identifying opportunities to integrate COB, subrogation, FWA, and payment integrity data to improve savings identification and recovery outcomes.
• Experience defining business requirements, user stories, acceptance criteria, and product specifications.