Senior Consultant, Payment Integrity

🔥 1 minute ago

🍂 Massachusetts – Remote

🍂 Massachusetts – Remote

⏰ Full Time

🟠 Senior

💼 Consultant

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Abacus Insights

WebsiteLinkedInAll Job Openings

51 - 200 employees

🏥 Healthcare

💼 Consulting

📦 Logistics

Healthcare • Consulting • Logistics

Abacus Insights is a leader in health plan data solutions that empowers healthcare payers by providing usable and interoperable data. The company offers a comprehensive suite of data solutions designed to address complex government mandates and improve payer readiness. Abacus Insights' platform is capable of consolidating and normalizing diverse data sources into comprehensive patient records, ensuring data accuracy, and facilitating timely data updates. Their solutions support multiple use cases, including risk adjustment, clinical data exchange, cost management, and performance reporting. With a focus on technology and healthcare, Abacus Insights helps payers manage costs and improve member experiences through enhanced data management capabilities.

📋 Description

• 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

🎯 Requirements

• 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

🏖️ Benefits

• 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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