Complex Clinical Audit (CCA) Business Solutions Lead
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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.
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Abacus Insights
View Company ProfileAbacus Insights (operating under abacusinsights.com, legally Abacus Insights, Inc.) is the premier, enterprise-grade healthcare data usability platform, compliance pioneer, and health plan orchestration powerhouse engineered to act as the definitive, high-velocity data curation, interoperability compliance, and analytical enrichment layer for healthcare payers and health insurance networks across the United States. Founded in 2017 by visionary physician entrepreneur Minalkumar Patel, MD alongside co-founder Gokul Varadharaj, the company completely eliminates the severe systemic friction of modern health plan administration—where crucial member claims, clinical notes, and electronic medical record (EMR) data remain trapped in legacy, siloed infrastructure, driving up costs and delaying medical necessity determinations—by deploying its purpose-built cloud-native data architecture. Moving far beyond traditional, passive electronic data interchange pipelines or generalized big data warehouses, Abacus Insights natively unifies automated multi-source clinical data ingestion, real-time validation scoring, Centers for Medicare & Medicaid Services (CMS) interoperability compliance enforcement, and AI-accelerated predictive analytics into a high-availability healthcare operating workspace. Managing comprehensive health logs for over 23 million commercial and government-insured members, the platform transforms messy, unstandardized records into clean, standardized datasets. Reflecting its immense category leadership and market validation, the high-growth software-as-a-service (SaaS) giant has secured over $94.9 million in institutional venture capital from elite investors including CRV, .406 Ventures, Echo Health Ventures, and major healthcare groups like Horizon Blue Cross Blue Shield. Under the hood, its technology framework utilizes an advanced data lakehouse core built on Databricks and Snowflake architectures, incorporating a structured bronze-silver-gold medallion architecture, natural language processing (NLP) models for parsing unstructured EMR profiles, and strict SOC 2 Type II and HIPAA-compliant data pipelines configured to distribute secure real-time SQL analytical feeds to internal teams with absolute execution correctness. What sets Abacus Insights apart is its uncompromising dedication to replacing fragile, high-maintenance custom data mappings with structured data usability, upstream provider data normalization, and immediate payer leverage; by bridging the gap between high-volume, highly regulated relational healthcare streams and predictive digital health workflows, the enterprise remains a definitive cornerstone of modern algorithmic health tech and global payer infrastructure transformation.
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