Senior Consultant, Payment Integrity

🕒 Novembro 3

🍂 Massachusetts – Remoto

🍂 Massachusetts – Remote

⏰ Tempo Integral

🟠 Sênior

💼 Consultor

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Abacus Insights

SiteLinkedInTodas as Vagas

51 - 200 funcionários

🏥 Saúde

💼 Consultoria

📦 Logística

Healthcare • Consulting • Logistics

A Abacus Insights é uma líder em soluções de dados para planos de saúde que capacita os pagadores de saúde, fornecendo dados utilizáveis e interoperáveis. A empresa oferece um conjunto abrangente de soluções de dados projetadas para atender a complexos mandatos governamentais e melhorar a prontidão dos pagadores. A plataforma da Abacus Insights é capaz de consolidar e normalizar diversas fontes de dados em registros de pacientes completos, garantindo a precisão dos dados e facilitando atualizações rápidas. Suas soluções suportam múltiplos casos de uso, incluindo ajuste de riscos, troca de dados clínicos, gestão de custos e relatórios de desempenho. Com foco em tecnologia e saúde, a Abacus Insights ajuda os pagadores a gerenciar custos e melhorar a experiência dos membros através de capacidades aprimoradas de gerenciamento de dados.

Descrição

• Own workstreams on client engagements from scoping and hypothesis development through analysis, recommendation, and implementation • Lead client discovery sessions, workshops, steering committee updates, and executive readouts • Diagnose issues, present data-backed recommendations, and secure buy-in from executives and payer sponsors • Serve as Abacus’ internal subject matter expert and trusted advisor for payment integrity strategy, claims accuracy, and policy • Investigate market, industry, and regulatory trends in payment integrity • Analyze compliance with federal, state, and ERISA regulations • Research contracts and design tailored payment integrity strategies, policies, and roadmaps • Create and maintain payment integrity policy for external communication • Lead cross-functional teams through implementation • Manage client relationships and expectations, including scope, timelines, risks, and value realization • Bring client and market insights to Product, Engineering, and Data/Analytics teams • Apply interoperability standards to improve audit and record-retrieval workflows • Configure and validate Payment Integrity accelerators in client Snowflake or Databricks environments • Contribute to consulting methodologies, reusable frameworks, accelerators, and thought leadership

🎯 Requisitos

• Consulting background at a top-tier global firm or leading healthcare-focused advisory firm • Typically 5+ years of consulting experience, including client-facing delivery within a healthcare payer practice, ideally in payment integrity, claims, or reimbursement • 10+ years of total experience in healthcare payment integrity, claims auditing, or reimbursement analysis • Experience across clinical, operational, and data domains • Hypothesis-driven problem solving, structured analysis, executive-ready storytelling, and workstream leadership • Deep hands-on knowledge of claims auditing workflows and claim types, including Inpatient/DRG validation, Outpatient modifiers, Post-Acute Care, Medical Necessity, and Specialty/High Cost Drugs • Experience developing, writing, and presenting payment integrity policy, strategy, and roadmaps • Strong grasp of reimbursement models, payer/provider operations, and regulatory considerations • Familiarity with provider risk arrangements, including delegated risk, capitation, and risk panels • Working knowledge of federal, state, and ERISA regulations • Experience identifying and mitigating fraud, waste, and abuse • Experience reviewing contracts for compliance and responding to audits and escalated appeals • Proven experience leading client relationships and engagements, including discovery sessions, workshops, and executive presentations • Comfort traveling to client sites as needed • Strong, polished communication skills and executive presence • Bachelor’s degree required

🏖️ Benefícios

• Unlimited paid time off • Work from anywhere • Comprehensive health coverage with multiple plan options • Equity for every employee • Growth-focused environment and development opportunities • Home office setup allowance • Monthly cell phone allowance • Eligibility for performance bonuses • Equity grants

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