Payment Integrity Product Development Specialist
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AI Summary
The specialist will serve as the primary subject matter expert to translate SNF regulatory and clinical requirements into scalable audit methodologies and product workflows. They will define the product roadmap, validate claim selection logic, and ensure the program is clinically sound and compliant with state and federal regulations.
Position Summary
At MedReview, our mission is to bring accuracy, accountability, and clinical excellence to healthcare. As such, we are a leading authority in payment integrity solutions.
The Payment Integrity Product Development Specialist (Skilled Nursing Facility or SNF SME) supports the development and launch of our SNF Payment Integrity audit product. This role is ideal for a clinical or operational leader who understands SNF regulations, medical necessity criteria, PDPM, MDS/RAI, and the drivers of improper payments. The SME will translate this expertise into scalable audit methodologies, workflows and product requirements as well as shaping a program that is clinically sound, compliant, operationally efficient and aligned with state and federal regulations.
Responsibilities:
Preferred Experience
At MedReview, our mission is to bring accuracy, accountability, and clinical excellence to healthcare. As such, we are a leading authority in payment integrity solutions.
The Payment Integrity Product Development Specialist (Skilled Nursing Facility or SNF SME) supports the development and launch of our SNF Payment Integrity audit product. This role is ideal for a clinical or operational leader who understands SNF regulations, medical necessity criteria, PDPM, MDS/RAI, and the drivers of improper payments. The SME will translate this expertise into scalable audit methodologies, workflows and product requirements as well as shaping a program that is clinically sound, compliant, operationally efficient and aligned with state and federal regulations.
Responsibilities:
- Serve as the primary SNF domain expert for the product development team by translating regulatory and clinical requirements into audit rules, workflows and operational processes.
- Validate and refine SNF audit methodology, including medical necessity criteria, documentation standards and coding requirements.
- Define MVP scope, roadmap enhancements and implementation readiness.
- Apply deep knowledge of CMS SNF regulations, PDPM, MDS/RAI, therapy documentation and state Medicaid policies.
- Monitor regulatory updates and recommend product adjustments as needed.
- Define and validate claim selection logic, risk indicators and scoring models.
- Develop and validate end-to-end workflows, including intake, clinical review, provider outreach and appeals.
- Define SLA expectations for turnaround times, provider response windows and internal review cycles.
- Support training for clinical reviewers, auditors and provider engagement teams.
- Define reporting needs for audit outcomes, savings, provider trends and operational KPIs. Partner with analytics to ensure dashboards and reporting tools are accurate and actionable.
- Identify opportunities for continuous improvement based on audit results.
- Serve as SME during product implementation, ensuring all components are ready for deployment.
Required Qualifications:
- 5-10+ years of experience in Skilled Nursing Facility clinical operations, utilization management, payment integrity or audit programs.
- Strong understanding of CMS SNF regulations, PDPM, MDS/RAI, therapy documentation and medical necessity criteria.
- Experience developing or executing clinical audit programs for Medicaid, Medicare and/or commercial payors.
- Familiarity with claims data, coding standards and documentation requirements.
- Ability to translate complex clinical and regulatory concepts into clear operational and product requirements.
- Strong communication, analytical and data comprehension skills.
Preferred Experience
- RN, PT, OT, SLP or other clinical licensure.
- Experience with payment integrity vendors, health plans or state Medicaid agencies.
- Background in product development or clinical audit solution design.
- Experience developing claims scoring models or working with analytics teams.
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