Director of Payment Integrity Business Solutions, Abacus Insights

• 10+ years of hands-on experience at a payer or payer vendor in a product or operational role with focus on complex claims auditing
• Deep, hands-on knowledge of end-to-end complex claims auditing workflows
• Clinical training or active coding certification
• Expertise in one or more of the following complex claim types: Inpatient (DRG validation), Outpatient (modifiers), Post-Acute Care, Medical Necessity, Specialty/High Cost Drugs
• Knowledge of payer-side data systems (claims adjudication platforms, audit automation engines, care management systems)
• Familiarity with audit-relevant regulatory frameworks: CMS guidelines, Medicare/Medicaid audit requirements, RAC/MAC/OIG standards
• Ability to translate complex clinical and operational requirements into clear product and technical specifications for non-clinical stakeholders
• Demonstrated ability to engage, consult, and build trust with payer clients at the operational and leadership levels

Desirable

• Abacus Insights is seeking a Director, Payment Integrity Business Solutions – Claim Auditing to serve as a strategic leader to help build the next generation of AI-enabled claim auditing solutions for healthcare payers
• This is a high-impact, client-facing role for a seasoned payment integrity (PI) leader with claim auditing and complex case review experience
• You will serve as the primary subject matter expert (SME) for our claim auditing product line, working directly with payer clients - including IT and complex claim audit business teams, to shape how our solutions are designed, deployed, and refined
• This role sits at the intersection of clinical expertise, payment integrity operational workflows, and technology-driven innovation
• Serve as the internal and external SME for end-to-end claims auditing workflows, spanning both pre-pay and post-pay audit processes
• Partner with Product, Engineering, and AI teams to translate auditing workflows into intelligent, AI-powered solution requirements
• Act as our client-facing expert, partnering closely with Sales and Delivery on client/prospect meetings, product demos, discovery sessions, and client support
• Identify gaps between current product capabilities and real-world auditing needs; champion a roadmap that closes those gaps
• Represent the voice of the complex case review audit team in cross-functional product discussions, ensuring clinical accuracy and operational practicality
• Partner with product and growth marketing on sales enablement, growth marketing initiatives, thought leadership, and GTM execution