Payment Integrity Subject Matter Expert - Inpatient/Outpatient

We are seeking experienced Inpatient and Outpatient Payment Integrity Subject Matter Experts (SMEs) to support the identification of overpayment opportunities, development of new audit concepts, enhancement of existing concepts, and improvement of payment integrity analytics. This role requires deep knowledge of healthcare claims, coding, reimbursement, audit outcomes, and billing patterns across inpatient and outpatient settings.

The SME will collaborate closely with analytics, clinical, coding, operations, and technology teams to translate healthcare billing expertise and claim-level insights into scalable, high-performing audit concepts, business rules, and automated selection strategies.

This is a part-time, temporary position requiring up to 20 hours per week. Work hours may vary based on project needs, audit concept development priorities, and collaboration requirements with analytics and operational teams. Project is expected to last 4-6 months.

*Base Pay Range: $75.00 - $100.00/hr

For more information on benefits and what we offer please visit us at https://www.exlservice.com/us-careers-and-benefits

Responsibilities

• Develop New Payment Integrity Concepts: Research potential overpayment and incorrect billing scenarios identified through analytics and convert findings into clearly defined audit concepts that can ultimately be automated.
• Analyze No-Finding Audits: Review completed audits resulting in no findings to determine the underlying reasons and categorize them into meaningful major and sub-category drivers. Use these insights to improve selection accuracy and reduce unnecessary audits.
• Identify New Opportunities: Analyze inpatient/outpatient claims, billing patterns, utilization trends, and healthcare spend to identify new areas of potential payment leakage and develop concepts to address them.
• Improve Existing Concept Performance: Evaluate existing concepts to identify opportunities to improve hit rate, precision, savings yield, and overall concept performance.
• Perform Detailed Data Analysis: Conduct claim-level and population-level analysis to understand patterns, outliers, false positives, and missed opportunities and use these insights to expand or refine existing concepts.
• Expand Existing Concepts: Identify additional codes, procedures, diagnoses, providers, specialties, claim types, or billing scenarios that can broaden the coverage and savings potential of successful concepts.
• Support Selection Automation: Review existing manual claim-selection processes and translate SME decision logic into clearly defined rules and requirements that analytics and technology teams can automate.
• Partner with Analytics: Work closely with data scientists and analytics teams to validate hypotheses, define selection criteria, test new concepts, analyze results, and continuously optimize models and rules.

Qualifications

• Minimum of 5 years of experience in healthcare claims auditing, medical coding, clinical review, payment integrity, healthcare reimbursement, or related healthcare operations.

• Demonstrated experience working with inpatient and/or outpatient claims, including claim forms, procedure codes, diagnosis codes, revenue codes, modifiers, billing patterns, and reimbursement rules.

• Strong working knowledge of healthcare coding guidelines, payer policies, medical necessity criteria, and common billing or payment error scenarios.

• Ability to interpret claim-level data, identify trends, validate audit opportunities, and distinguish between valid findings and no-finding outcomes.

• Experience collaborating with analytics, clinical, coding, operations, or technology teams to support audit concept development, selection logic, or process improvement initiatives.

• Strong written and verbal communication skills, with the ability to document audit logic, explain findings, and translate SME expertise into actionable business requirements.

• Proficiency with Microsoft Excel and the ability to work with reports, claim extracts, dashboards, or other healthcare data outputs.

• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Coding Specialist – Physician-based (CCS-P), Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT).

Preferred Certifications:

• Clinical certification such as Registered Nurse (RN), Licensed Practical Nurse (LPN), or other relevant clinical credentials are preferred for clinically oriented audit reviews.

• Certified Professional Medical Auditor (CPMA) or other healthcare audit-related certification is strongly preferred.

• Additional credentials in healthcare compliance, reimbursement, payment integrity, utilization management, or medical claims review are a plus.