Manage the full lifecycle of edit and audit development — from initial coding and billing hypothesis to detailed rule design.
Convert complex medical policy, CMS rules, AMA/CPT guidance, and coding regulations into actionable logic specifications, mapping out precise conditions, exclusions, thresholds, and flags.
Must be capable of running data queries to prove the financial validity of a coding and billing hypothesis and authoring the resulting technical specification document.
Design payment policies where CMS guidance needs to be supplemented to ensure defensibility in supporting the concept.
Post-release, improve concept efficacy, false positives, and provider abrasion, continuously refining active rules based on real-world results and updated behavioral trends.
Use large language models (LLMs) or automated pattern-matching tools to review claim trends and develop narratives, accelerating the translation of signal into active payment logic.
Connect identified billing anomalies directly to published primary defense sources, including CMS guidelines, NCCI bundling frameworks, LCD/NCD rules, and AMA coding mandates.
Plan, organize, and coordinate discrete initiatives and concepts to achieve specific, measurable payment accuracy goals and deadlines.
Partner with PI Directors, internal auditors, SIU, and claims operations to ensure coding and billing appropriateness, regulatory compliance, and cross-functional strategic alignment.

Bachelor's degree and a minimum of 4 years of relevant professional experience within a health plan, payment integrity vendor, or healthcare revenue cycle environment.
Proven subject matter expertise as a coding and billing regulations expert, with deep familiarity interpreting CMS policies (LCDs, NCDs, LCAs), NCCI bundling edits, and provider manuals.
Demonstrated experience and comfort with concept development logic, including a proven track record of writing logic rules or structural guidelines for claims processing implementation.
Demonstrated ability to plan, organize, and coordinate individual concepts and initiatives, utilizing strong problem-solving skills to clear operational obstacles and meet deadlines.
Strong analytical literacy with the ability to read, interpret, and validate data query scripts or advanced spreadsheets to confirm edit efficacy and check coding and billing hypotheses.

Employer sponsored health, dental and vision plan with low or no premium
Generous paid time off
$100 monthly mobile or internet stipend
Stock options for all employees
Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles
Parental leave program
401K program

Payment Integrity Program Development Manager

Key skills