Senior Consultant, Payment Integrity

Abacus Insights•Boston, MA

8h•Remote

About The Position

Payment Integrity is one of the highest-stakes problems in healthcare — and you’ll be Abacus’ internal authority on it: the trusted advisor and go-to Subject Matter Expert who helps us solve it right. The Senior Consultant, Payment Integrity is an individual-contributor role for a payment integrity practitioner with a consultant’s instincts: someone who can investigate a market trend, structure a policy recommendation, and walk an executive team through why it matters — all in the same week. As we launch new and expanded service offerings, you’ll be embedded directly in client engagements, building the solution alongside our delivery team and advising our payer clients directly. You will work as an embedded Payment Integrity SME on client delivery teams supporting these expanded offerings — sitting inside the client’s own environment alongside the Engagement Manager, Data/Platform Engineers, AI Engineers, and QA — translating PI policy and claims-auditing judgment into working claim-edit rules, review agents, and validation logic. Your work spans from market and regulatory research, through policy and rule design, to hands-on configuration, testing, and payer-facing rollout. This role sits at the intersection of payment integrity policy, regulatory compliance, and hands-on AI-enabled delivery.

Requirements

10+ years of experience in healthcare payment integrity, claims auditing, or reimbursement analysis, including 5+ years in a consulting or advisory capacity (payer, provider, risk-bearing entity, or consulting firm), with comfort working across clinical, operational, and data domains
Prior experience in a healthcare payer or provider consulting/advisory practice (e.g., a Big 4, boutique healthcare consultancy, or a technology/consulting firm’s payment integrity practice), or experience representing an organization externally on payment integrity (conference talks, publications, webinars, analyst briefings)
Deep, hands-on knowledge of complex claims auditing workflows and claim types (Inpatient/DRG validation, Outpatient modifiers, Post-Acute Care, Medical Necessity, Specialty/High Cost Drugs)
Consulting-style problem-solving: structuring ambiguous problems, running stakeholder workshops, and building a clear narrative from findings to recommendation
Experience developing, writing, and presenting payment integrity policy, strategy, and roadmaps for executive and sponsor audiences, backed by a strong grasp of reimbursement models, payer/provider operations, and regulatory considerations
Familiarity with provider risk arrangements (delegated risk, capitation, risk panels) and how payment integrity policy applies to them
Working knowledge of federal, state, and ERISA regulations, and experience identifying and mitigating fraud, waste, and abuse — including reviewing contracts for compliance and responding to audits and escalated appeals
Proven experience leading client relationships and engagements — discovery sessions, workshops, and executive presentations — with comfort traveling to client sites as needed
A strong, polished communicator with genuine executive presence — confident presenting recommendations to executives and provider sponsors alike

Nice To Haves

Six Sigma Black Belt, CPC, CCS, or CFE certification
Clinical training or an active coding certification (e.g., RHIA, RHIT, CCS)
Exposure to adjacent payment integrity disciplines including clinical claim editing, post-payment recovery, and Special Investigations
Exposure to Agile or lean product development environments
A genuine curiosity about healthcare tech, startups, and what makes companies grow
Exposure to AI or agent-based automation tools, or comfort partnering closely with engineers configuring claim-edit logic inside a cloud data platform (Snowflake, Databricks)

Responsibilities

Lead client discovery sessions, workshops, and presentations — diagnosing issues, presenting recommendations, and securing buy-in from executives and payer sponsors
Serve as Abacus’ internal subject matter expert and trusted advisor for sponsors and risk panels — the go-to authority on payment integrity strategy, claims accuracy, and policy, bridging clinical, operational, and data domains
Investigate market, industry, and regulatory trends in payment integrity, and analyze compliance with federal, state, and ERISA regulations to keep policy aligned
Research contracts and design tailored payment integrity strategies, policies, and roadmaps aligned with sponsor goals and industry best practices
Create and maintain payment integrity policy for external communication, and lead cross-functional teams through implementation
Bring client and market insights back to Product, partnering with Product, Engineering, and Data/Analytics teams to keep payment integrity outputs accurate and technically sound — including applying interoperability standards to improve audit and record-retrieval workflows
Configure and validate Abacus’ Payment Integrity accelerators — including prepay/postpay claim-edit review, prior-authorization-to-claim matching, and provider billing-anomaly detection — against each client’s specific policies and data, working inside their own Snowflake or Databricks environment