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Tier-1 brand, metro locations, and mid-level consulting role increase applicant competition.
Requires US health plan, coding and payment integrity expertise, making candidate fit highly domain-specific.
Explicit 6+ years, US payer experience, coding and analytics requirements enforce strict shortlisting.
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Lead and manage payment integrity programs for healthcare payer clients focusing on claim overpayment recovery and cost optimization.
Analyze medical and pharmacy claims to detect errors, fraud, waste, and compliance issues, implementing pre- and post-payment claim editing strategies.
Drive automation and AI-enabled payment integrity solutions while monitoring KPIs such as savings, accuracy, and audit yield; support product development and lead cross-functional teams.
Bachelor's degree required; Master's/MBA preferred.
6 - 15+ years experience in healthcare consulting, payment integrity, claims operations, or payer analytics.
Experience working with U.S. health plans or healthcare services organizations preferred.
Strong knowledge of U.S. healthcare payer ecosystem, claims processing, reimbursement methodologies, and coding systems (ICD-10, CPT, HCPCS, DRG).
Experienced in leading strategic payment integrity initiatives involving cross-functional teams in a consulting or healthcare payer environment.
Proficient in claims analytics with skills in SQL, Excel, and visualization tools (Power BI/Tableau), familiarity with AI/ML is advantageous.
Comfortable managing client relationships, delivering presentations, and driving cost-saving recommendations in a U.S. healthcare context.