[Hiring] Complex Clinical Audit Business Solutions Lead @Abacus Insights

Role Description

Payment Integrity lives at the intersection of clinical nuance and product logic — and the Complex Clinical Audit (CCA) Business Solutions Lead is where that intersection gets built. This is not a clinical license role — it's a deep payment integrity SME role for someone who has spent 5+ years embedded in payment integrity on the payer or vendor side of U.S. healthcare, and who understands how to turn that domain knowledge into the technical backbone of a product.

• Translate coding guidelines, MS-DRG definitions, and payer audit policy into workable product logic.
• Build prompts, connectors, and workflows that validate claims against medical records at scale.
• Work hands-on with AI Engineering on backend build, developing test scenarios and validation criteria for new audit capabilities.
• Demo product capabilities directly to clients, explaining data foundation and audit logic.
• Understand how CCA connects to the rest of payment integrity: COB, SIU, and fraud/waste investigation.

NOTE: This is a remote role with US working hours (Eastern time zone)

Qualifications

• 5+ years embedded in payment integrity on the payer or vendor side of U.S. healthcare.
• Experience building technical PI solutions: backend data engineering workflows, EMR/connector builds, or load-UI systems.
• Deep knowledge of U.S. healthcare payer payment integrity programs.
• Strong working knowledge across multiple PI domains: DRG audit, clinical validation, IBR, edit-based audits, observation, readmissions.
• Comfort being client-facing: demoing product and presenting to U.S. payer stakeholders.
• Experience translating audit operations, clinical content, and payer requirements into software workflows.
• Strong analytical and communication skills.
• Familiarity with claims processing, adjudication systems, and healthcare interoperability standards.
• Comfort using internal AI-enabled tools to prototype and visualize workflows.
• A track record of championing AI tools to accelerate ideation and solution design.

Requirements

• Experience partnering directly with Product Management, Engineering, Data Science, AI Engineering, or Clinical Informatics teams.
• Familiarity with Generative AI, Large Language Models (LLMs), Natural Language Processing (NLP), or healthcare AI applications.
• Understanding of recovery workflows, eligibility verification, and payment responsibility determinations.
• Familiarity with FWA investigation methods and healthcare fraud prevention programs.
• Experience identifying opportunities to integrate COB, subrogation, FWA, and payment integrity data.
• Experience defining business requirements, user stories, acceptance criteria, and product specifications.

Benefits

• Competitive Leave & Benefits
• Comprehensive health coverage
• Equity for every employee – share in our success
• Growth-focused environment – your development matters here

Company Description

As a mission-led technology company helping to drive better healthcare outcomes, Abacus Insights believes that the best innovation and value we can bring to our customers comes from diverse ideas, thoughts, experiences, and perspectives. Therefore, we dedicate resources to building diverse teams and providing equal employment opportunities to all applicants.

At the heart of who we are is a commitment to continuously and intentionally building an inclusive culture—one that empowers every team member across the globe to do their best work and bring their authentic selves.