Note: The job is a remote job and is open to candidates in USA. Commence delivers data-driven, technology-enabled, and clinically informed solutions to improve healthcare outcomes and operational efficiency. The Healthcare Program Integrity Solutions Consultant will provide commercial payer expertise in healthcare fraud, waste and abuse, payment integrity, and SIU operations while supporting sales, customer success, product, engineering, onboarding, and implementation. The role will translate payer workflows into technology solutions, support customer-facing activities, and identify opportunities for product growth.
Responsibilities
- Serve as the primary internal and external expert on commercial health plan payment integrity operations, including pre-payment review, post-payment recovery, SIU investigations, and provider fraud and billing scheme identification
- Develop and maintain payment integrity-focused documentation, use cases, and enablement materials for Sales, Pre-Sales, and Customer Success teams
- Partner with product management and engineering to ensure commercial payer payment integrity workflows and SIU operational realities are reflected in product design and roadmap decisions
- Stay current on commercial payer fraud trends, payment integrity best practices, HIPAA compliance requirements, and regulatory changes that impact health plan program integrity operations
- Identify new product opportunities based on emerging payment integrity trends, payer operational shifts, and evolving commercial health plan needs
- Represent Commence's payment integrity expertise at industry forums, payer-facing events, and conferences to strengthen credibility and visibility in the commercial health plan market
- Partner with sales teams to provide payment integrity and FWA domain expertise throughout the commercial sales cycle from initial discovery through close
- Help the sales team qualify and prioritize opportunities by identifying where Commence's platform creates the clearest operational fit and business value for commercial payer payment integrity departments
- Conduct structured discovery conversations to understand a prospect's current payment integrity operations, SIU structure, pre- and post-payment review processes, and investigation challenges
- Lead or participate in product demonstrations, serving as the domain voice that connects Commence's platform capabilities to the specific payment integrity workflows and SIU operations of each prospect
- Support RFP and RFI responses requiring payment integrity domain knowledge and commercial health plan context
Skills
- Bachelor's degree in healthcare administration, public health, business, or a related field
- Minimum of 5 years of hands-on experience in healthcare fraud, waste and abuse, payment integrity, or SIU operations within a commercial health plan, managed care organization, or health IT/analytics company serving commercial payers
- Deep knowledge of commercial payer payment integrity operations including pre-payment clinical review, post-payment auditing and recovery, provider fraud patterns, billing scheme identification, claims analysis, and SIU case management
- Demonstrated ability to translate operational payment integrity knowledge into practical technology use cases and client-facing solution narratives, not just describe how the payer world works, but show how technology changes it
- Strong written and verbal communication skills with the ability to engage credibly with SIU analysts, payment integrity directors, compliance officers, and C-suite payer stakeholders
- Ability to travel within the United States on a monthly basis
- Candidates must be able to sit, read, work on a computer, and watch a computer screen for extended periods of time. Occasionally required to stand, walk, use hands and fingers, kneel or crouch
- Prior experience in a client-facing, solutions consulting, or vendor-facing role within a healthcare technology, analytics, or payment integrity company
- Experience working with commercial payer procurement, vendor evaluation, and technology adoption cycles from either the buyer or seller side
- Familiarity with fraud detection platforms, payment integrity solutions, case management tools, or clinical review technologies used in commercial payer environments
- Certified Fraud Examiner (CFE), Certified in Healthcare Compliance (CHC), or similar credential
Benefits
- Remote work opportunity for candidates in AZ, AR, DE, FL, GA, IL, IN, KS, KY, MA, MD, MI, MS, MO, MT, NC, NE, NV, NY, OH, OK, PA, SC, TN, TX, VA, DC, WI, and WV
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