Position Purpose: The Lead Payment Integrity Systems Specialist is the senior individual contributor and enterprise-level subject-matter expert for Payment Integrity systems, platform governance, analytics, financial reporting, and operational visibility. The role sets technical and operating standards, leads complex cross-platform analysis, advises leadership, shapes prioritization decisions, and drives solutions across Operations, Technology, Finance, and governance stakeholders.
- Lead enterprise-level analysis of complex Payment Integrity system, claims, workflow, financial, and reporting data to identify strategic risks, prioritization decisions, savings opportunities, and operational improvement recommendations.
- Set standards for technical review, data validation, dashboarding, reporting routines, ServiceNow intake, defect/enhancement prioritization, UAT/release readiness, post-release issue tracking, and operational visibility.
- Serve as the senior business-technology liaison for platform change management, aligning Operations, Technology, Finance, governance, and leadership stakeholders on scope, impact, risk, decisions, and readiness.
- Own operating routines that prioritize and govern incidents, defects, enhancements, releases, automation opportunities, and modernization workstreams across Payment Integrity systems.
- Translate complex cross-platform results into executive-ready summaries, strategic recommendations, implementation plans, and measurable success criteria.
- Advise leadership on platform governance, financial reporting considerations, data quality controls, process standardization, and long-term system capability needs.
- Lead the design and continuous improvement of methodologies, standards, and job-family consistency across Payment Integrity system support and analytics functions.
- Provide technical leadership, coaching, peer review, and escalation support to PI Systems Specialist I, II, and Senior PI Systems Specialist team members.
- Performs other duties as assigned.
- Complies with all policies and standards.
Education/Experience:
Bachelor's Degree in healthcare, business, finance, accounting, information systems, data analytics, or a related field, or equivalent experience required.
5+ years years of relevant experience in Payment Integrity systems, managed care claims systems, platform governance, financial reporting, healthcare analytics, business analysis, UAT/release readiness, or related technical healthcare function. required.
Specialized depth and/or breadth of expertise in Payment Integrity systems, claims data, operational workflows, data governance, financial reporting, system dependencies, and cross-functional transformation. required.
Advanced proficiency with SQL, reporting/analytics tools such as Power BI, financial reporting tools, Excel, ServiceNow or similar ticketing/workflow platforms, and executive-level data storytelling. required.
Demonstrated ability to lead technical direction, resolve precedent-setting issues, influence without formal authority, and communicate with senior leaders. required.
Platform Support & Governance required.
Data Validation & Reporting required.
UAT / Regression Testing required.
Defect & Enhancement Intake required.
Release Readiness required.
Financial Systems / Reporting required.
Dashboard / KPI Development required.
Configuration & Edit Support required.
Related Payment Integrity systems and technology support functions required.
Advanced knowledge of financial systems and accounting principles preferred. preferred.
Experience setting platform governance, operational visibility standards, dashboard/reporting strategy, release-readiness routines, and cross-functional technology operating models. preferred.
License/Certification:
- Advanced credentials in data analytics, business analysis, healthcare data, project/program management, Lean Six Sigma, finance/accounting, SQL, or related systems disciplines. preferred
- License/Certification: LPN, RN, CPC, CPC-H, CPC-P, CCS, CCS-P, RHIT, RHIA, or CPMA. RHIT, CCS, CIC, CCDS. preferred
Pay Range: $87,000.00 - $161,300.00 per year
