Payment Integrity Program Development Senior Manager – Clinical & Facility Specialist

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Payment Integrity Program Development Senior Manager – Clinical & Facility Specialist based in the United States. This is a high-impact, highly autonomous role focused on developing innovative payment integrity strategies across the healthcare claims ecosystem. You will serve as a clinical and coding subject-matter expert, identifying payment anomalies and transforming complex clinical and regulatory insights into automated claim-edit solutions. The role spans inpatient, outpatient, ambulatory surgical center, and professional billing environments, with a particular emphasis on complex and high-value care. You will combine clinical research, healthcare policy expertise, coding knowledge, and data analysis to create new concepts from the ground up. Working closely with clinical, claims, legal, and investigative teams, you will influence policy and drive concepts through implementation and optimization. Modern AI tools can support data analysis and research, creating an environment that values both deep expertise and innovative technology. Identify new payment integrity opportunities: Research clinical literature, specialty society guidelines, medical policies, and billing trends across inpatient, outpatient, ASC, and professional settings to uncover payment anomalies and develop original claim-edit concepts. Design automated payment logic: Translate clinical documentation, coding frameworks, coverage policies, and billing regulations into detailed logic and parameters suitable for claims editing platforms. Validate concepts with data: Analyze real-world claims and clinical data to test hypotheses, assess financial potential, refine rules, and establish parameters that minimize unnecessary provider friction. Lead cross-functional policy development: Present original concepts to senior leaders and collaborate with Clinical Operations, Special Investigations, Claims, Legal, and other stakeholders to build alignment around new policies and rule architectures. Own concepts from discovery to optimization: Manage the full lifecycle of payment integrity initiatives, including clinical research, selection criteria, logic testing, launch, post-launch refinement, and ongoing performance monitoring. Apply expertise across care settings: Use strong clinical, coding, and facility billing knowledge to develop impactful solutions across complex inpatient and high-dollar claims as well as outpatient, ASC, and professional services. Requirements Clinical and coding credentials: Active Registered Nurse (RN) license with direct inpatient clinical experience, such as ICU or Med-Surg, combined with an active professional coding certification such as CPC, CCS, CCS-P, or RHIA. Payment integrity experience: At least 5 years of experience creating and authoring new payment integrity claim edits within a health plan or vendor environment, rather than primarily evaluating existing edit catalogs or implementing client-requested solutions. Medicare and regulatory expertise: Strong knowledge of Medicare regulations, billing requirements, Local and National Coverage Determinations (LCDs/NCDs), and NCCI edit logic across multiple healthcare settings. Multi-setting billing expertise: Deep understanding of inpatient MS-DRG/APR-DRG, outpatient and ASC APC/OPPS and fee schedules, as well as professional CPT/HCPCS coding and clinical guidelines. Logic development experience: Hands-on experience writing detailed rules and structural specifications for commercial claims-editing engines or proprietary payer platforms. Research and analytical skills: Ability to synthesize complex clinical and specialty guidelines into structured, actionable logic and interpret and validate data queries, with modern AI tools available to assist with SQL generation. Executive communication and influence: Excellent storytelling, presentation, and stakeholder-ma