Payment Integrity Concept Develpment SME

About the Role

The Subject Matter Expert (SME) – Payment Integrity Concept Development designs, develops, and validates innovative payment integrity concepts that identify inaccurate, inappropriate, or unsupported healthcare claims. This role combines deep expertise in medical coding, reimbursement methodologies, clinical documentation, regulatory guidance, and claims analytics to create high-value overpayment detection opportunities that generate measurable savings. The ideal candidate has a proven history of successfully developing new payment integrity concepts from initial idea through implementation, resulting in significant financial recoveries while maintaining high clinical accuracy and low provider abrasion.

Responsibilities

• Develop new payment integrity concepts by identifying emerging coding, billing, reimbursement, and documentation vulnerabilities.
• Perform detailed analysis of professional, outpatient facility, ASC, and hospital claims to identify potential overpayment opportunities.
• Translate coding guidelines, CPT®, HCPCS, ICD-10-CM/PCS, NCCI edits, CMS regulations, payer policies, and specialty society recommendations into scalable claims editing logic.
• Design claims selection criteria using CPT, HCPCS, ICD-10 diagnosis, revenue codes, modifiers, units, place of service, device codes, and other claims attributes.
• Validate concepts through claims research, medical record review, and provider documentation analysis.
• Collaborate with data analysts and engineers to convert clinical concepts into production-ready algorithms and SQL logic.
• Evaluate concept performance using savings, precision, hit rate, provider appeal rates, false-positive rates, and return on investment.
• Identify trends in coding changes, emerging procedures, new technologies, and reimbursement methodologies that may create new payment integrity opportunities.
• Serve as the clinical and coding expert during concept implementation, client discussions, and audit support.

Requirements

• Bachelor's degree in Health Information Management, Nursing, Healthcare Administration, or related field (or equivalent experience).
• Minimum 3 - 5 years of healthcare payment integrity, medical coding, clinical auditing, or claims analytics experience.
• Demonstrated success developing original payment integrity concepts that achieved measurable savings.

Qualifications

• Extensive knowledge of:
  • CPT®, HCPCS Level II, and ICD-10-CM/PCS
  • CMS regulations and reimbursement methodologies
  • NCCI Policy Manual and Correct Coding Initiative edits
  • OPPS, ASC, and physician fee schedule reimbursement
  • Commercial payer reimbursement policies
  • Medical necessity and clinical documentation requirements
• Experience interpreting operative reports, procedure notes, and medical records.
• Strong analytical and critical thinking skills with the ability to recognize complex billing patterns.
• Experience working with large healthcare claims databases and translating clinical logic into technical requirements.
• Excellent written and verbal communication skills.

Preferred Qualifications

• CPC®, CCS®, RHIA®, RHIT®, CPMA®, CIRCC®, or equivalent certification.
• Experience with SQL or working closely with data engineering teams.
• Experience supporting AI-assisted payment integrity or predictive analytics initiatives.
• Knowledge of high-cost implant validation, specialty procedure coding, device-to-procedure relationships, and emerging medical technologies.
• Experience developing concepts across multiple specialties including gastroenterology, ophthalmology, cardiovascular, orthopedics, vascular surgery, general surgery, interventional radiology, and dialysis access procedures.

Pay

Base Pay Range: $75,100 - $107,300/yr

Benefits

For information on benefits, visit EXL Service Careers and Benefits.