Director, Payment Integrity Business Solutions – Claim Auditing

Abacus Insights • Boston, MA

3d • Remote

About The Position

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.

Requirements

• 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

Nice To Haves

• Exposure to adjacent payment integrity disciplines including clinical claim editing, post-payment recovery, fraud/waste/abuse (FWA) detection, and Special Investigations
• Exposure to Agile or lean product development environments

Responsibilities

• 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

Benefits

• 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
• 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 This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: No Education Listed
• Number of Employees: 11-50 employees