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Abacus Insights is an AI and data platform for payer intelligence, helping health plans break down data silos and create a trusted data foundation to improve outcomes, reduce waste, and deliver better member and provider experiences. Backed by $100M in funding, the company is transforming how data and AI work in healthcare.
The Senior Consultant, Payment Integrity is an individual-contributor role for a payment integrity practitioner with consulting expertise. You will serve as Abacus' internal subject matter expert and trusted advisor on payment integrity strategy, claims accuracy, and policy. This role sits at the intersection of payment integrity policy, regulatory compliance, and hands-on AI-enabled delivery.
Day-to-day responsibilities include:
- Lead client discovery sessions, workshops, and executive presentations to diagnose issues, present recommendations, and secure buy-in from payer sponsors
- Serve as the go-to authority on payment integrity strategy, bridging clinical, operational, and data domains
- Investigate market, industry, and regulatory trends in payment integrity; analyze compliance with federal, state, and ERISA regulations
- 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 implementation
- Partner with Product, Engineering, and Data/Analytics teams to keep payment integrity outputs accurate and technically sound
- Configure and validate Abacus' Payment Integrity accelerators (prepay/postpay claim-edit review, prior-authorization-to-claim matching, provider billing-anomaly detection) against each client's specific policies and data in Snowflake or Databricks environments
- Work embedded on client delivery teams alongside Engagement Managers, Data/Platform Engineers, AI Engineers, and QA, translating PI policy and claims-auditing judgment into working claim-edit rules, review agents, and validation logic
The role offers unlimited paid time off, work-from-anywhere flexibility, comprehensive health coverage, equity for every employee, a growth-focused environment, home office setup allowance, and monthly cell phone allowance.
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., Big 4, boutique healthcare consultancy, or 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, building clear narratives from findings to recommendations
- Experience developing, writing, and presenting payment integrity policy, strategy, and roadmaps for executive and sponsor audiences, backed by 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; experience identifying and mitigating fraud, waste, and abuse; experience reviewing contracts for compliance and responding to audits and escalated appeals
- Proven experience leading client relationships and engagements (discovery sessions, workshops, executive presentations) with comfort traveling to client sites as needed
- Strong communicator with genuine executive presence; confident presenting recommendations to executives and provider sponsors
NICE-TO-HAVE:
- Six Sigma Black Belt, CPC, CCS, or CFE certification
- Clinical training or active coding certification (RHIA, RHIT, CCS)
- Exposure to adjacent payment integrity disciplines (clinical claim editing, post-payment recovery, Special Investigations)
- Exposure to Agile or lean product development environments
- Genuine curiosity about healthcare tech, startups, and company growth
- Exposure to AI or agent-based automation tools, or comfort partnering with engineers configuring claim-edit logic in cloud data platforms (Snowflake, Databricks)
