Senior Consultant, Payment Integrity
Abacus Insights · United States
About Us
Abacus Insights is transforming how data and AI work for health plans. Our mission is simple: make healthcare data usable, so the people responsible for care and cost decisions can act faster, with confidence.
As the AI and Data Platform for Payer Intelligence, we help health plans break down data silos to create a single, trusted data foundation. That foundation powers better decisions—so plans can improve outcomes, reduce waste, and deliver better experiences for members and providers alike. Backed by $100M from top investors, we're tackling big challenges in an industry that's ready for change. Our platform enables GenAI use cases by delivering clean, connected, and reliable healthcare data to support automation, prioritization, and decision workflows—and it's why we are leading the way.
Our innovation begins with people. We are bold, curious, and collaborative—because the best ideas come from working together. We embrace the thoughtful use of AI and automation to drive innovation and efficiency, and we look for individuals who are curious and adaptable—those excited to leverage emerging technologies to enhance how we work—while keeping human insight, connection, and our clients at the center of every decision.
Ready to make an impact? Join us and let's build the future together.
About the Role
Payment Integrity is one of the highest-stakes problems in healthcare — and you’ll be Abacus’ internal authority on it: the trusted advisor and go-to Subject Matter Expert who helps us solve it right. The Senior Consultant, Payment Integrity is an individual-contributor role for a payment integrity practitioner with a consultant’s instincts: someone who can investigate a market trend, structure a policy recommendation, and walk an executive team through why it matters — all in the same week. As we launch new and expanded service offerings, you’ll be embedded directly in client engagements, building the solution alongside our delivery team and advising our payer clients directly.
You will work as an embedded Payment Integrity SME on client delivery teams supporting these expanded offerings — sitting inside the client’s own environment alongside the Engagement Manager, Data/Platform Engineers, AI Engineers, and QA — translating PI policy and claims-auditing judgment into working claim-edit rules, review agents, and validation logic. Your work spans from market and regulatory research, through policy and rule design, to hands-on configuration, testing, and payer-facing rollout. This role sits at the intersection of payment integrity policy, regulatory compliance, and hands-on AI-enabled delivery.
Your day to day
- Lead client discovery sessions, workshops, and presentations — diagnosing issues, presenting recommendations, and securing buy-in from executives and payer sponsors
- Serve as Abacus’ internal subject matter expert and trusted advisor for sponsors and risk panels — the go-to authority on payment integrity strategy, claims accuracy, and policy, bridging clinical, operational, and data domains
- Investigate market, industry, and regulatory trends in payment integrity, and analyze compliance with federal, state, and ERISA regulations to keep policy aligned
- Research contracts and design tailored payment integrity strategies, policies, and roadmaps aligned with sponsor goals and industry best practices
- Create and maintain payment integrity policy for external communication, and lead cross-functional teams through implementation
- Bring client and market insights back to Product, partnering with Product, Engineering, and Data/Analytics teams to keep payment integrity outputs accurate and technically sound — including applying interoperability standards to improve audit and record-retrieval workflows
- Configure and validate Abacus’ Payment Integrity accelerators — including prepay/postpay claim-edit review, prior-authorization-to-claim matching, and provider billing-anomaly detection — against each client’s specific policies and data, working inside their own Snowflake or Databricks environment
What you bring to the team
- 10+ years of experience in healthcare payment integrity, claims auditing, or reimbursement analysis, including 5+ years in a consulting or advisory capacity (payer, provider, risk-bearing entity, or consulting firm), with comfort working across clinical, operational, and data domains
- Prior experience in a healthcare payer or provider consulting/advisory practice (e.g., a Big 4, boutique healthcare consultancy, or a technology/consulting firm’s payment integrity practice), or experience representing an organization externally on payment integrity (conference talks, publications, webinars, analyst briefings)
- Deep, hands-on knowledge of complex claims auditing workflows and claim types (Inpatient/DRG validation, Outpatient modifiers, Post-Acute Care, Medical Necessity, Specialty/High Cost Drugs)
- Consulting-style problem-solving: structuring ambiguous problems, running stakeholder workshops, and building a clear narrative from findings to recommendation
- Experience developing, writing, and presenting payment integrity policy, strategy, and roadmaps for executive and sponsor audiences, backed by a strong grasp of reimbursement models, payer/provider operations, and regulatory considerations
- Familiarity with provider risk arrangements (delegated risk, capitation, risk panels) and how payment integrity policy applies to them
- Working knowledge of federal, state, and ERISA regulations, and experience identifying and mitigating fraud, waste, and abuse — including reviewing contracts for compliance and responding to audits and escalated appeals
- Proven experience leading client relationships and engagements — discovery sessions, workshops, and executive presentations — with comfort traveling to client sites as needed
- A strong, polished communicator with genuine executive presence — confident presenting recommendations to executives and provider sponsors alike
What we’d like to see, but not required
- Six Sigma Black Belt, CPC, CCS, or CFE certification
- Clinical training or an active coding certification (e.g., RHIA, RHIT, CCS)
- Exposure to adjacent payment integrity disciplines including clinical claim editing, post-payment recovery, and Special Investigations
- Exposure to Agile or lean product development environments
- A genuine curiosity about healthcare tech, startups, and what makes companies grow
- Exposure to AI or agent-based automation tools, or comfort partnering closely with engineers configuring claim-edit logic inside a cloud data platform (Snowflake, Databricks)
Compensation
Compensation for this role is based on experience, skills, and location, and includes base salary plus eligibility for performance bonuses and equity grants.
What you’ll get in return
- Unlimited paid time off – recharge when you need it
- Work from anywhere – flexibility to fit your life
- Comprehensive health coverage – multiple plan options to choose from
- Equity for every employee – share in our success
- Growth-focused environment – your development matters here
- Home office setup allowance – one-time support to get you started
- Monthly cell phone allowance – stay connected with ease
Our Commitment as an Equal Opportunity Employer
As a mission-led technology company helping to drive better healthcare outcomes, Abacus Insights believes that the best innovation and value we can bring to our customers comes from diverse ideas, thoughts, experiences, and perspectives. Therefore, we dedicate resources to building diverse teams and providing equal employment opportunities to all applicants. Abacus prohibits discrimination and harassment regarding race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.
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