100% remote in US
$120,000-135,000 + 10% yearly bonus
REQUIRED: 4 or more years of experience in healthcare claims editing, payment integrity, medical coding, reimbursement, medical policy, or claims analytics.
About the Role
The Product Owner, Claims Editing identifies, designs, and supports the implementation of automated claim edits that drive incremental value, improve payment accuracy, and generate revenue across claims-editing programs. The role initially focuses on Routine Test Management (RTM), with potential support for Routine Radiology Management (RRM) and Genetic Testing Management (GTM).
This position partners with Scientific Affairs and Coding & Translation to review existing and emerging policies, identify opportunities for additional claims enforcement, and translate approved requirements into clear, configuration-ready rules. The role also analyzes claims data using approved AI tools to estimate financial impact, collaborates with Configuration and APEA Development on testing and implementation, and supports Product and Account Management with training, claim examples, and client adoption.
Responsibilities
- Maintain a prioritized pipeline of opportunities to enhance existing policies and develop new automated claim edits.
- Review medical policies, coding guidance, regulatory updates, and new publications in collaboration with Scientific Affairs and Coding & Translation to identify opportunities for additional enforcement.
- Translate approved policy requirements into clear, testable business rules and configuration specifications, including codes, triggers, exclusions, and expected outcomes.
- Evaluate existing claim-editing capabilities and recommend new functionality when needed.
- Analyze claims data using approved AI/LLM tools and other analytical methods to estimate eligible claim volume, potential savings, incremental revenue, and client impact.
- Develop claim examples and test scenarios, coordinate handoffs to Configuration, and validate claim-editing decisions and outcomes.
- Create training materials, process walkthroughs, FAQs, and decisioning examples for Product, Account Management, and clients.
- Monitor implemented edits and recommend enhancements to improve accuracy, financial performance, and client adoption.
- Serve as a key liaison among Product, Scientific Affairs, Coding & Translation, Configuration, APEA Development, Account Management, and Analytics to ensure alignment throughout the edit development lifecycle.
Minimum Qualifications
- 4+ years of experience in healthcare claims editing, payment integrity, medical coding, reimbursement, medical policy, or claims analytics.
- Bachelor's degree in a related field, or 8+ years of directly applicable experience.
- Working knowledge of healthcare claims, claims adjudication, medical coding systems, and automated claim-editing concepts.
- Demonstrated ability to translate medical, coding, or reimbursement policies into clear, testable business rules.
- Experience analyzing claims data and estimating operational and financial impact using Excel, SQL, business intelligence tools, or similar analytical solutions.
- Familiarity with generative AI and large language models (LLMs), including the ability to validate AI-assisted outputs against authoritative sources.
- Strong analytical, documentation, presentation, and cross-functional communication skills.
Preferred Qualifications
- Direct experience developing, testing, or implementing automated claim edits or payment-integrity rules.
- Experience with laboratory, genetic testing, radiology, or other medical-benefit claims.
- Experience working at a health plan, claims-editing vendor, payment-integrity organization, or healthcare technology company.
- Familiarity with APEA or another claims-editing platform.
- Experience with SQL, data visualization, Agile methodologies, or client training.
By submitting to this position, you are agreeing to be included in our talent pool for future hiring for similarly qualified positions.
