Payment Integrity AI and Analytics Project Management

Gainwell Technologies is focused on improving health and well-being through advanced technologies. In this role, you will provide strategic and technical leadership in designing and implementing AI-enabled analytics solutions to enhance claims accuracy and identify improper payments across healthcare domains.

Responsibilities:

• Act as Product Owner, Delivery Lead, and Implementation Manager for complex data mining and analytics initiatives within the Systems Integration group
• Design, develop, and implement advanced data mining and AI-driven analytics concepts to identify overpayments and improper payments across medical, dental, and pharmacy claims
• Support and lead responses to client RFPs, contributing superior written content related to data mining, AI, and payment integrity capabilities
• Translate complex healthcare regulations, reimbursement methodologies, and clinical policies into scalable audit algorithms and analytic rules
• Research and apply CMS regulations, State and Federal guidelines, coding standards, and industry best practices to claims data and payment integrity initiatives
• Lead the incorporation of AI, machine learning, and advanced analytics techniques (e.g., anomaly detection, predictive modeling, NLP, pattern recognition) into payment integrity solutions
• Partner with data science and engineering teams to ensure AI solutions are explainable, auditable, compliant, and operationally scalable
• Ensure AI-driven solutions align with regulatory requirements, client policies, and ethical AI standards
• Serve as a senior mentor and subject matter expert, guiding and developing analysts, content designers, and project team members
• Partner with clinical, operations, appeals, validation, and client services teams to resolve production issues and support ongoing audits
• Drive continuous improvement of audit processes, analytics, and delivery methodologies

Requirements:

• 7+ years of Healthcare Payment Integrity, Data Mining, or Advanced Analytics experience
• Demonstrated experience in healthcare payment integrity data mining, including validation of claims data accuracy and payment accuracy
• Proven experience applying CMS regulations, State/Federal guidelines, coding standards, and reimbursement policies to claims analytics
• Strong experience translating business and policy requirements into technical and analytical solutions
• Hands-on experience with AI/ML-driven analytics, such as predictive modeling, anomaly detection, pattern recognition, or NLP applied to healthcare or financial data
• Ability to articulate AI-driven insights clearly to technical and non-technical stakeholders