This role as Product Owner for Claims Editing is responsible for identifying, designing, and supporting automated claim edits that improve payment accuracy and help drive revenue. You will work cross-functionally to turn approved medical and reimbursement policies into configuration-ready rules, analyze claims data using approved AI tools, and support end-to-end testing, training, and continuous optimization.
Key Responsibilities
- Maintain a prioritized pipeline of opportunities to improve 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 additional enforcement opportunities.
- Convert approved policy requirements into clear, testable business rules and configuration specifications, including codes, triggers, exclusions, and expected outcomes.
- Assess current claim-editing capabilities and recommend new functionality when gaps are identified.
- 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.
- Act as a key liaison across Product, Scientific Affairs, Coding & Translation, Configuration, APEA Development, Account Management, and Analytics to ensure alignment throughout the edit development lifecycle.
Required 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.
- Proven 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 solutions.
- Familiarity with generative AI and 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.
Technologies
- Excel
- SQL
- AI/LLM tools
- Generative AI
- Large language models (LLMs)
Role Focus and Collaboration
The Product Owner, Claims Editing supports automated claim edits across claims-editing programs, with an initial focus on Routine Test Management (RTM). The position may also support Routine Radiology Management (RRM) and Genetic Testing Management (GTM).
You will partner with Scientific Affairs and Coding & Translation to review existing and emerging policies, identify opportunities for additional claims enforcement, and translate approved requirements into configuration-ready rules. You will also analyze claims data using approved AI tools to estimate financial impact, collaborate with Configuration and APEA Development on testing and implementation, and support Product and Account Management with training, claim examples, and client adoption.
Location and Compensation
- Location: Tampa, FL (remote)
- Salary: USD 120,000 - 135,000 per year
