Payment Integrity Product Development Specialist
On-site · New York City, New York, United States
Job Summary
Lead SNF payment integrity product development by translating regulatory and clinical requirements into scalable audit rules, workflows and product requirements. Define MVP scope and implementation readiness, apply CMS SNF regulations and PDPM/MDS/RAI knowledge to validate and refine audit methodologies, and define claim selection logic, scoring models, and end-to-end workflows (including intake, clinical review, provider outreach, and appeals). Collaborate with analytics for dashboards and reporting of outcomes, savings, provider trends and KPIs; establish SLA expectations and training support for clinical reviewers and provider engagement teams; identify opportunities for continuous improvement based on audit results.
Required Qualifications
- 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
Desired Qualifications
- RN, PT, OT, SLP or other clinical licensure (preferred)
- 5-10+ years of experience in Skilled Nursing Facility clinical operations, utilization management, payment integrity or audit programs
- Experience developing or executing clinical audit programs for Medicaid, Medicare and/or commercial payors
- Background in product development or clinical audit solution design
- Experience developing claims scoring models or working with analytics teams
- Strong communication, analytical and data comprehension skills
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