The Medical Appeals Specialist reconciles appeals received from providers and serves as a primary point of contact between the MAC and internal departments. They are responsible for processing appeal documents, ensuring regulatory compliance, and recommending workflow improvements.
The Document Specialist manages document workflows, including processing, quality assurance, and routing claims to auditors. They also analyze data trends, reconcile balances, and identify system issues to improve operational efficiency.
You will own the end-to-end technical and operational lifecycle of client migrations, from legacy system analysis to production deployment. This involves orchestrating cross-functional collaboration and building scalable, automated migration pipelines.
You will set the technical direction for backend systems and design scalable, cloud-native services to support payment-integrity decisions. You will also mentor engineers, collaborate cross-functionally, and own your services in production to ensure reliability and performance.
The Healthcare Reclamation Analyst investigates coverage, eligibility, and primacy issues to recover funds for clients who have paid in error. They communicate with insurance carriers to resolve claim discrepancies and ensure compliance with HIPAA and internal policies.
The Medical Review Nurse performs retrospective and prepayment medical claims audits for government clients while applying appropriate medical review guidelines. They also document findings, generate audit letters, and support findings during the appeals process.
The Medical Review Nurse II performs retrospective and prepayment audits on skilled nursing facility claims to ensure medical appropriateness and compliance. They also document findings, generate audit letters, and support the appeals process while collaborating with clients and internal teams.
You will set the technical direction for backend development and design scalable, reliable web application systems while collaborating with AI coding agents. You will also act as a developer coach, setting standards and mentoring team members to elevate overall programming maturity.
The Director of Quality Assurance Engineering will define the quality strategy and organizational design across the full software development lifecycle. They will lead a high-performing team to implement AI-driven technical quality architectures and establish rigorous release standards.
Collaborate with clients and internal stakeholders to integrate analytical outputs with payment integrity requirements and claims adjudication systems. Drive AI adoption by developing automated workflows and maintaining complex SQL queries against large-scale healthcare datasets.
Lead the development, testing, and optimization of payment integrity audit concepts across government and commercial healthcare claims. Collaborate with cross-functional teams to ensure audit concepts align with coding standards, regulatory requirements, and payer policies.
The role involves scaling inherited Scala systems, redesigning the data layer for AI products, and building a Rust framework for performant services. Additionally, the engineer will drive AI tool adoption and improve platform observability and resilience.
Perform medical claims audit reviews specifically for the Home Health sector for government and commercial payers. Document findings based on medical review guidelines and support these findings during the appeals process.
Perform detailed clinical and coding reviews of facility claims to ensure billing accuracy and appropriateness of care. Develop complex claims review content and act as a subject matter expert for client initiatives and internal training.
Investigates health insurance claims to identify recoverable funds from liable third parties. Negotiates with insurance adjusters, attorneys, and members while documenting findings and processing recovery payments.
Oversee quality assurance for DRG Reviewers to ensure adherence to clinical and coding standards. Conduct training sessions for new and existing staff to enhance skills and maintain compliance.
The Claims Administrator supports efficient claims processing by reviewing incoming claims, organizing data, and routing files to auditors. They are also responsible for managing import queues, reconciling balances, and monitoring data transfer accuracy.
Provide legal support and guidance to subrogation recovery teams and the General Counsel. Ensure adverse suits are handled appropriately and train analysts on relevant legal statutes and regulations.
Lead the engineering team in building a scalable, AI-driven cloud-native solution for Coordination of Benefits (COB). Own the technical roadmap, architecture, and production releases while managing and coaching a team of 5-6 engineers.
Lead the transformation of pharmacy payment integrity from manual workflows to AI-first automation, owning the roadmap for AI agents and voice AI. Design automated payment recovery workflows and redesign customer-facing analytics portals to demonstrate ROI.
Perform secondary reviews of outpatient coding validation audits to ensure accuracy, consistency, and compliance with regulatory standards. Monitor auditor performance, provide coaching, and develop quality assurance tools to improve operational excellence.
Lead and grow the AI/ML Engineering team to design, deliver, and operate a scalable core AI/ML platform. Partner with the Chief AI Officer to bridge the gap between data science proof-of-concepts and production-grade services.
Extract hidden patterns and insights from large healthcare datasets to drive business strategy and operational efficiency. Lead small data projects and create comprehensive reports and visualizations to communicate results to diverse audiences.
Design and build scalable, reliable full-stack web applications that apply ML techniques to large volumes of data. Balance the development of new customer-facing features with technical debt cleanup to ensure software sustainability.
Own end-to-end data science workflows to build and productionize ML and LLM-powered solutions for healthcare payment intelligence. Lead high-impact initiatives and set technical direction through mentorship and design reviews to improve business outcomes.
Develop and refine product messaging, positioning, and value propositions to translate complex AI capabilities into clear narratives for healthcare payers. Support the creation of sales enablement tools, video content, and the coordination of product launches.
You will own the end-to-end product lifecycle for the Coordination of Benefits (COB) line, including strategy, roadmap, and execution. You will drive the vision for AI-native workflows to improve claims recovery and operational efficiency.
Conduct comprehensive outpatient payment validation reviews to ensure accurate coding, billing, and compliance with payer policies. Document audit findings and provide well-supported rationales for reimbursement impacts using industry-standard references.
The analyst will review facility insurance claims and itemized statements to ensure the accuracy of charges against medical documentation and compliance guidelines. They will also collaborate with internal teams to improve claim review efficiency and assist in content development and research.
The Software Architect will own the design and implementation of the intelligent document processing and agentic evaluation framework. This role involves hands-on technical leadership, defining system abstractions, and ensuring the platform scales to process healthcare documents at a high volume.
The Senior Director will lead end-to-end business development across federal and state government markets, focusing on Medicaid and federal health agencies. They will manage the full sales cycle, including RFP responses, strategic partnerships, and policy-driven market positioning.
You will drive the data product roadmap by partnering with engineering and architecture leadership to translate business needs into technical requirements. The role involves coordinating the consolidation of legacy systems into a unified AI-powered platform while enabling new product capabilities across the healthcare payment continuum.
Develop and advance machine learning models to optimize healthcare claim audits and improve financial outcomes. Create technical frameworks and data pipelines to enhance team efficiency and model precision.
The role involves conducting thorough DRG payment validation reviews, including clinical and coding assessments of medical records to ensure accurate payment determinations based on contract-specific criteria. Key duties include meticulously documenting findings, providing clinical and policy support, and collaborating with stakeholders to maintain compliance with payment standards.
The role involves designing and building scalable, high-performance data software solutions primarily using Golang and Python, while also building and deploying Kubernetes-based systems for containerized applications in cloud-native environments. Engineers will collaborate cross-functionally to optimize backend infrastructure performance, reliability, and security, focusing on data transformation for machine learning workflows.
This role is responsible for leading the build and deployment of classical Machine Learning and Generative AI systems to generate and validate concepts related to billing errors, audits, and fraud within large-scale healthcare payment data. The Staff Data Scientist will own the end-to-end delivery process, from problem framing and data strategy through model development, evaluation, deployment, and monitoring, focusing on reliability and customer outcomes.
The Data Scientist will translate complex medical policies and clinical criteria into executable SQL and Python code, focusing on building robust clinical feature pipelines from extracted signals in medical records. They will also own the measurement, evaluation, and continuous quality improvement of the AI system responsible for extracting structured clinical information.
The Staff Data Scientist will be responsible for advancing machine learning models used for identifying and auditing claims errors, requiring deep dives into clinical and coding data to improve audit precision. This role also involves enhancing data pipelines, modeling infrastructure, and team tools to scale capabilities and ensure model insights align with real business needs.
Develop new applications and contribute to UI and middle-layer development. Collaborate with team and external stakeholders to design and implement solutions for an intuitive user experience.
The DRG Reviewer will conduct thorough DRG payment validation reviews, including clinical and coding assessments of medical records according to contract-specific criteria. This involves meticulously documenting findings, providing clinical and policy support, and collaborating with stakeholders to ensure compliance with payment standards.
