Payment Accuracy Manager, Outpatient Facility
Overview
As a Payment Accuracy Policy Manager, you will serve as a critical bridge between healthcare payment expertise in our facility capability. This role combines deep subject matter knowledge with strategic influence—driving the development of payment integrity policies that protect our clients while advancing Rialtic's platform capabilities.
You'll lead the research, evaluation, and implementation of new policies based on CMS guidelines, Medicaid requirements, industry standards, and emerging medical cost trends in the facility space of our offering. Working closely with client management, product, engineering, and content leadership teams, you'll translate complex payment policy concepts into actionable strategies that deliver measurable value. This is an opportunity to shape how health plans approach payment integrity and to build the content foundation that powers our enterprise platform.
Responsibilities
- Serve as the SME for outpatient facility editing policy development, leading the research, scoping, and creation of new claims editing policies for the facility capability
- Source, interpret, and scope new payment integrity policies to expand Rialtic's claims editing content library from outpatient facility claims
- Prioritize policy updates based on savings potential, client impact, and strategic alignment with platform goals
- Leverage CMS, Medicaid, clinical guidelines, and industry trends to identify opportunities for new content development for facility claims
- Quantify and communicate policy value through data-driven analysis and clear financial impact assessments in the facility space
- Work closely with product and engineering teams to ensure client needs inform platform development, building out our facility capability
- Collaborate with content leadership to maintain consistency, quality, and relevance across the policy library
- Perform investigation of current facility policy defects and unexpected claim outcomes, performing root cause analysis and policy research to identify corrective actions and improve policy accuracy and performance
- Serve as the facility payment accuracy SME in client discussions, presenting policy concepts and addressing facility-related questions when needed
Qualifications
Required
- 5-7 years of experience in payment integrity at a health plan, claims editing vendor, or similar healthcare organization with focus in outpatient facility claims editing and reimbursement methodologies
- Active coding certification (COC, CPC, CCS, or equivalent specialty certification) — required for this position
- Proven expertise in:
- Interpreting medical and payment policies
- Applying CMS and Medicaid reimbursement guidelines
- Professional and outpatient coding standards
- Common claims payment error identification and resolution
- Demonstrated ability to advise clients and explain complex payment accuracy concepts in clear, accessible terms
- Strong analytical skills with experience quantifying policy impact and ROI
- Track record of managing claims editing implementations or similar client-facing initiatives
- Intermediate Excel skills (i.e., formulas, v-lookups, pivot tables, etc)
Preferred
- Expertise across both professional and institutional claims environments
- Advanced proficiency with Google Suite or similar collaboration tools
- Experience working cross-functionally with product and engineering teams in a SaaS or health tech environment
- Exceptional written and verbal communication skills with the ability to influence stakeholders at all levels
