Healthcare Program Integrity Solutions Consultant

🕒 Julho 27

🌵 Arizona, Florida, +22 estados a mais – Remoto

🌵 Arizona – Remote 🐊 Florida – Remote 🌽 Illinois – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote 🦬 Montana – Remote 🌾 Nebraska – Remote 🎰 Nevada – Remote 🗽 New York – Remote 🌲 North Carolina – Remote 🏈 Ohio – Remote 🌪️ Oklahoma – Remote 🦀 Maryland – Remote 🍂 Massachusetts – Remote 🚗 Michigan – Remote 🎸 Mississippi – Remote 🏰 Missouri – Remote 🔔 Pennsylvania – Remote 🌴 South Carolina – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⚔️ Virginia – Remote ⛰️ West Virginia – Remote 🧀 Wisconsin – Remote

💵 $150.000 - $175.000 / ano

⏰ Tempo Integral

🟡 Pleno

🟠 Sênior

💻 Engenheiro de Soluções

👻 Score fantasma 39%

O que significa: quão provável esta vaga está aberta sem contratação ativa.Como ler: 60% ou mais significa que achamos que é uma vaga fantasma. Pontuações mais baixas preocupam menos.Como pontuamos: tempo em aberto, republicações, vagas abertas vs tamanho do time, rapidez para fechar vagas, e se o salário está divulgado.Observação: é uma estimativa de dados públicos, não um julgamento da empresa. Vagas reais podem ter pontuação alta, então use como uma dica, não como um fato.

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Commence

SiteLinkedInTodas as Vagas

501 - 1000 funcionários

🏥 Saúde

🏛️ Governo

🤖 Inteligência Artificial

Healthcare • Government • Artificial Intelligence

A Commence é uma empresa de dados e tecnologia de saúde que oferece soluções centradas em dados para tornar os dados de saúde mais acessíveis, descobertos e interoperáveis. A empresa combina expertise clínica com transformação de dados impulsionada por IA e uma plataforma tecnológica para tratar de fraudes, desperdícios e abusos, resolução de disputas independentes, revisões por pares e independentes, melhoria de qualidade e defesa do paciente. A Commence atende agências federais de saúde (CMS, VA, Agência de Saúde de Defesa), programas governamentais estaduais e locais e clientes de saúde comerciais, focando em melhorar resultados, precisão e integridade do programa.

Descrição

• Serve as a trusted authority on healthcare fraud, waste and abuse, payment integrity operations, and Special Investigative Unit functions • Support sales, customer success, product, and engineering teams with payment integrity domain expertise • Bridge commercial payer operational knowledge with technology and demonstrate how the Commence platform maps to FWA and payment integrity workflows • Provide domain support during customer onboarding and implementation • Serve as the primary internal and external expert on commercial health plan payment integrity operations • Develop and maintain payment integrity documentation, use cases, and enablement materials • Partner with product management and engineering on product design and roadmap decisions • Monitor commercial payer fraud trends, payment integrity best practices, HIPAA compliance requirements, and regulatory changes • Identify new product opportunities based on payment integrity trends and evolving commercial health plan needs • Represent Commence's payment integrity expertise at industry forums, payer-facing events, and conferences • Partner with sales throughout the commercial sales cycle from initial discovery through close • Help qualify and prioritize opportunities based on operational fit and business value • Conduct structured discovery conversations about payment integrity operations, SIU structure, review processes, and investigation challenges • Lead or participate in product demonstrations • Support RFP and RFI responses requiring payment integrity domain knowledge • Travel within the United States on a monthly basis

🎯 Requisitos

• Bachelor's degree in healthcare administration, public health, business, or a related field • Minimum of 5 years of hands-on experience in healthcare fraud, waste and abuse, payment integrity, or SIU operations within a commercial health plan, managed care organization, or health IT/analytics company serving commercial payers • Deep knowledge of commercial payer payment integrity operations, including pre-payment clinical review, post-payment auditing and recovery, provider fraud patterns, billing scheme identification, claims analysis, and SIU case management • Ability to translate operational payment integrity knowledge into practical technology use cases and client-facing solution narratives • Strong written and verbal communication skills • Ability to engage credibly with SIU analysts, payment integrity directors, compliance officers, and C-suite payer stakeholders • Ability to travel within the United States on a monthly basis • Prior experience in a client-facing, solutions consulting, or vendor-facing role within a healthcare technology, analytics, or payment integrity company • Experience working with commercial payer procurement, vendor evaluation, and technology adoption cycles • Familiarity with fraud detection platforms, payment integrity solutions, case management tools, or clinical review technologies • Certified Fraud Examiner (CFE), Certified in Healthcare Compliance (CHC), or similar credential • Remote candidates must be located in AZ, AR, DE, FL, GA, IL, IN, KS, KY, MA, MD, MI, MS, MO, MT, NC, NE, NV, NY, OH, OK, PA, SC, TN, TX, VA, DC, WI, or WV

🏖️ Benefícios

• Remote work option • Reasonable accommodations for individuals with disabilities • Equal employment opportunity