Complex Clinical Audit (CCA) Business Solutions Lead

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.

You'll translate coding guidelines, MS-DRG definitions, and payer audit policy into workable product logic — building the prompts, connectors, and workflows that let us validate claims against medical records at scale. You'll work hands-on with AI Engineering on the backend build, developing test scenarios and validation criteria for new audit capabilities, and you'll be the person in the room with clients: demoing what we've built, explaining our data foundation, and showing payers how we solve their pain points across the payment integrity landscape.

This role sits at the center of a fast-growing product suite — starting in Complex Clinical Audit and expanding into itemized bill review and beyond — and you'll need to understand not just CCA but how it connects to the rest of payment integrity: COB, SIU, and fraud/waste investigation. If you've lived in the payer or vendor side of PI, know your way around a UB-04 and stop-loss reimbursement, and want to help build the product rather than just operate it, this is your seat at the table.

• Serve as the primary operational SME for payment integrity methodologies, audit programs, and product requirements across Complex Clinical Audit.
• Translate coding clinic guidelines, MS-DRG definitions, payer contract language, and audit policy into product capabilities and workable prompts against medical records.
• Partner directly with AI Engineering to build connectors, prompts, and load-UI workflows — working in a “shift-left” model with AI doing the heavy lifting and a human in the loop.
• Develop test scenarios and validation criteria for new audit capabilities and AI features.
• demo product capabilities directly to clients at major U.S. payer organizations, explaining data foundation, audit logic, and how we solve their PI pain points.
• Define savings opportunities, validation criteria, and defensibility standards across priority PI domains.
• Understand and apply deep knowledge of UB-04 structures, itemized bills, and stop-loss reimbursement and how each affects DRG weighting.
• Support roadmap prioritization, pilot launches, outcome reviews, positioning, and customer expansion conversations.