Complex Clinical Audit Business Solutions Lead

About Us Abacus Insights is transforming how data works for health plans. Our mission is simple: make healthcare data usable, so the people responsible for care and cost decisions can act faster, with confidence. We help health plans break down data silos to create a single, trusted data foundation. That foundation powers better decisions—so plans can improve outcomes, reduce waste, and deliver better experiences for members and providers alike. Backed by $100M from top investors, we’re tackling big challenges in an industry that’s ready for change. Our platform enables GenAI use cases by delivering clean, connected, and reliable healthcare data to support automation, prioritization, and decision workflows—and it’s why we are leading the way. Our innovation begins with people. We are bold, curious, and collaborative—because the best ideas come from working together. We embrace the thoughtful use of AI and automation to drive innovation and efficiency, and we look for individuals who are curious and adaptable—those excited to leverage emerging technologies to enhance how we work—while keeping human insight, connection, and our clients at the center of every decision. Ready to make an impact? Join us and let’s build the future together. About the Role The Complex Clinical Audit Business Solutions Lead is a clinical, operational, and product-facing expert who translates payment integrity audit knowledge into scalable product capabilities. This role supports pre-pay and post-pay programs (Complex Clinical Audit), including DRG validation, clinical claim review, itemized bill review, claim editing, readmissions, and observation. The Business Solutions Lead, Payment Integrity, partners with product, engineering, AI Engineering, clinical, operations, customer success, and payer stakeholders to define audit logic, identify savings opportunities, reduce provider abrasion, and improve product accuracy and defensibility. Your day to day Serve as the primary operational subject matter expert for payment integrity methodologies, audit programs, and product requirements. Translate payer pain points, contract language, audit policy, and operational workflows into product capabilities. Define audit concepts, savings opportunities, validation criteria, and defensibility standards across priority PI domains. Partner with engineering to define, develop, and build high-performing, scalable, trustworthy, reliable, and accurate AI solutions. Support roadmap prioritization, pilot launches, outcome reviews, positioning, and customer expansion. What you bring to the team 5–10+ years of progressive experience in Payment Integrity, healthcare audit, clinical operations, or healthcare technology product management. Deep knowledge of U.S. healthcare payer payment integrity programs, including pre-pay and post-pay audit strategies, vendor management, savings methodologies, recovery operations, and performance measurement. Understanding of payer regulatory, compliance, and audit considerations that impact payment integrity program design and execution. 3+ years in a PI-domain leadership role, such as audit operations, PI program management, vendor product management, or payer PI strategy. Strong working knowledge across multiple PI domains, including DRG audit, clinical validation, IBR, edit-based audits, observation, readmissions, COB, SIU, and UM adjacencies. Experience translating audit operations, clinical content, and payer requirements into software workflows, analytics, or product requirements. Strong analytical and communication skills, with comfort using hit-rate analysis, ROI modeling, outcome measurement, and executive-ready narratives. Familiarity with claims processing, adjudication systems, provider billing, UB-04 data structures, and healthcare interoperability standards. Utilize internal AI-enabled tools to quickly create prototypes, visualize workflows, and showcase product functionality, enabling effective communication of product vision and business value. Champion the use of internal AI tools to accelerate ideation, solution design, and demonstration of product capabilities, helping stakeholders understand requirements, opportunities, and proposed outcomes. What we would like to see, but not required Experience partnering directly with Product Management, Engineering, Data Science, AI Engineering, or Clinical Informatics teams to build software solutions. Familiarity with Generative AI, Large Language Models (LLMs), Natural Language Processing (NLP), prompt engineering, or healthcare AI applications. Understanding of recovery workflows, eligibility verification, accident-related claims, third-party liability, workers’ compensation, and other payment responsibility determinations. Familiarity with FWA investigation methods, claim anomaly detection, provider billing patterns, and healthcare fraud prevention programs. Experience identifying opportunities to integrate COB, subrogation, FWA, and payment integrity data to improve savings identification and recovery outcomes. Experience defining business requirements, user stories, acceptance criteria, and product specifications. Compensation: Compensation for this role is based on experience, skills, and location, and includes base salary plus eligibility for performance bonuses and equity grants. What you’ll get in return: Unlimited paid time off – recharge when you need it Work from anywhere – flexibility to fit your life Comprehensive health coverage – multiple plan options to choose from Equity for every employee – share in our success Growth-focused environment – your development matters here Home office setup allowance – one-time support to get you started Monthly cell phone allowance – stay connected with ease Our Commitment as an Equal Opportunity Employer 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. Abacus prohibits discrimination and harassment regarding race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws. 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. We carry that same commitment into our hiring process, aiming to create an interview experience where you feel comfortable and confident showcasing your strengths. If there’s anything we can do to support that—big or small—please let us know.