MedReview Inc. helps payors identify inaccurate medical claims to save millions in overpayments.
Payment Integrity Product Development Specialist
Location
United States
Posted
3 hours ago
Salary
0
Seniority
Senior
Job Description
Payment Integrity Product Development Specialist
MedReview Inc.
• 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.
Job Requirements
- 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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