Payment Integrity Product Development Specialist

🔥 0 minutes ago

Apply Now

Find Similar Remote Jobs

Receive Emails For Remote Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

MedReview Inc.

WebsiteLinkedInAll Job Openings

201 - 500 employees

⚕️ Healthcare Insurance

💸 Finance

Healthcare Insurance • Finance

MedReview Inc. is a leading provider of advanced payment integrity solutions, specializing in healthcare claims. They work with a wide range of clients, including health plans, government agencies, and payors, to reduce unnecessary waste and save billions of dollars. Their team of highly trained physicians, registered nurses, and certified coders conduct thorough clinical and coding reviews to identify inaccuracies in healthcare claims. MedReview employs proprietary algorithms to analyze complex data and detect suspicious payment trends, offering a unique blend of clinical expertise and advanced technology to maximize efficiencies and improve healthcare cost management.

📋 Description

• Serve as the primary SNF domain expert for the product development team by translating regulatory and clinical requirements into audit rules, workflows and operational processes. • Validate and refine SNF audit methodology, including medical necessity criteria, documentation standards and coding requirements. • Define MVP scope, roadmap enhancements and implementation readiness. • Apply deep knowledge of CMS SNF regulations, PDPM, MDS/RAI, therapy documentation and state Medicaid policies. • Monitor regulatory updates and recommend product adjustments as needed. • Define and validate claim selection logic, risk indicators and scoring models. • Develop and validate end-to-end workflows, including intake, clinical review, provider outreach and appeals. • Define SLA expectations for turnaround times, provider response windows and internal review cycles. • Support training for clinical reviewers, auditors and provider engagement teams. • Define reporting needs for audit outcomes, savings, provider trends and operational KPIs. • Partner with analytics to ensure dashboards and reporting tools are accurate and actionable. • Identify opportunities for continuous improvement based on audit results. • Serve as SME during product implementation, ensuring all components are ready for deployment.

🎯 Requirements

• 5-10+ years of experience in Skilled Nursing Facility clinical operations, utilization management, payment integrity or audit programs. • Strong understanding of CMS SNF regulations, PDPM, MDS/RAI, therapy documentation and medical necessity criteria. • Experience developing or executing clinical audit programs for Medicaid, Medicare and/or commercial payors. • Familiarity with claims data, coding standards and documentation requirements. • Ability to translate complex clinical and regulatory concepts into clear operational and product requirements. • Strong communication, analytical and data comprehension skills. • Preferred Experience RN, PT, OT, SLP or other clinical licensure. • Experience with payment integrity vendors, health plans or state Medicaid agencies. • Background in product development or clinical audit solution design. • Experience developing claims scoring models or working with analytics teams.