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Overview

Position Overview:

We are seeking a Senior Payment Integrity Specialist to play a key role in building and implementing proprietary healthcare edits that drive cost savings and accuracy in claims processing. The successful candidate will be responsible for taking a senior level role in analyzing claims data, as well as translating contract terms, policies, and regulatory guidelines into actionable requirements for our proprietary edit library. This role involves close collaboration with subject matter experts, technical teams, and internal/external partners to ensure the effectiveness and relevance of our edits.

The Product:

With Source , we’re changing the industry narrative, providing a more holistic approach to payment integrity that focuses on comprehensive reimbursement, agile editing, and integrated analytics. Our interoperable, cloud-based solution is modular to meet a health plan’s needs today and extensible to grow with their organization over time—bringing disparate parts of a payer’s organization together for improved accuracy and insights. The Source platform offers the ability for clients to unlock transformation at the reimbursement, payment integrity, and enterprise level. Our Reimbursement Transformation features Medicare and Medicaid content coupled with flexible contract configuration capabilities for Commercial lines of business. Payment Integrity Transformation includes rich editing libraries with history-based capabilities, easy development of customized edits, and improved transparency to reduce vendor dependency and increase control. As a complete solution, clients can achieve Enterprise Transformation, where root-cause issues are identified and addressed upstream, and all aspects of claims operations are centralized for comprehensive business intelligence. The complete suite of solutions from HealthEdge delivers a digital foundation for payers specifically designed to fuel a digital transformation, reduce costs, and improve both clinical outcomes and the member experience.

Your Impact:

• Develop requirements for proprietary healthcare edits, conducting comprehensive reviews of contracts, policies, and state/federal guidelines.

• Drive collaboration with subject matter experts and technical teams to translate these requirements into functional specifications for our proprietary healthcare edits.

• Own the communication of proposed proprietary healthcare edits to internal and external stakeholders, ensuring clarity and addressing any questions or concerns.

• Be responsible for creating and maintaining detailed documentation to support the building and implementation of proprietary healthcare edits, including specifications, test plans, and user guides.

• Provide continuous monitoring and evaluation of the performance of proprietary healthcare edits, proactively identifying opportunities for optimization and enhancement based on industry trends and regulatory changes. This is a role for a leader who is ready to take ownership and drive a team of analysts towards success.

What You Bring:

• Bachelor’s degree in Healthcare Administration, Business, Finance, Computer Science, or a related field. Industry experience and a proven track record of success in combination with a bachelor’s degree.

• Minimum of 3 years of experience in healthcare payment integrity, content & policy, contracts, claims processing, or a closely related field, with a strong understanding of healthcare contracts, policies, and regulatory guidelines.

• Proven track record of developing and implementing proprietary healthcare edits, and/or healthcare content & policy, preferably within a software development or healthcare IT environment.

• Excellent communication and interpersonal skills, with the ability to effectively collaborate with cross-functional teams and communicate technical concepts to non-technical stakeholders.

• Strong analytical and problem-solving abilities, with a detail-oriented approach to reviewing contracts, policies, and regulatory guidelines.

• Experience with documentation management tools and methodologies, such as Confluence or SharePoint.

HealthEdge commits to building an environment and culture that supports the diverse representation of our teams. We aspire to have an inclusive workplace. We aspire to be a place where all employees have the opportunity to belong, make an impact and deliver excellent software and services to our customers.

Geographic Responsibility: While HealthEdge is located in Burlington, MA you may live anywhere in the US

Type of Employment: Full-time, permanent

Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job:

• The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

• Work across multiple time zones in a hybrid or remote work environment.

• Long periods of time sitting and/or standing in front of a computer using video technology.

• May require travel dependent on company needs.

The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required. HealthEdge reserves the right to modify, add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990. Candidates may be required to go through a pre-employment criminal background check.

HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities.

#LI-Remote

Job Locations US-Remote

ID 2024-4956

Category Hidden (28999)

Position Type Full-Time

HealthEdge provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.