Healthcare Program Integrity Solutions Consultant

Description

At Commence, we’re the start of a new age of data-centric transformation, elevating health outcomes and powering better, more efficient process to program and patient health. We combine quality data-driven solutions that fuel answers, technology that advances performance, and clinical expertise that builds trust to create a more efficient path to quality care. 

With human-centered, healthcare-relevant, and value-based solutions, we create new possibilities with data. We provide proof beyond the concept and performance beyond the scope with a focus on efficiencies that transform the lives of those we serve. With a culture driven by purpose, straightforward communication and clinical domain expertise, Commence cuts straight to better care.

Requirements

The Healthcare Program Integrity Solutions Consultant will play a significant role in the growth and success of Commence in the commercial payer market. The ideal candidate serves as a trusted authority on healthcare fraud, waste and abuse, payment integrity operations, and Special Investigative Unit (SIU) functions, and brings that expertise directly to bear in support of sales, customer success, product, and engineering teams.

This is a domain-first, solutions-oriented role. The right candidate understands how payment integrity departments and SIU teams operate day to day inside commercial health plans. Additionally, this candidate has the ability to bridge that operational knowledge with technology, helping prospective customers see how the Commence platform maps to their real-world FWA and payment integrity workflows. This person serves as the trusted domain voice throughout the commercial sales cycle and beyond. This role also provides domain support during customer onboarding and implementation to ensure the platform aligns with each client's payment integrity workflows.

Payment Integrity & FWA Domain Expertise

• 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

Sales & Pre-Sales Support

• 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

Qualifications

• 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

Preferred Qualifications

• 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

*Commence' headquarters are in Virginia Beach, VA, however we are open to remote candidates in the following states:   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* 

Work Environment/Physical Demands 

The work environment and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

This is an office/remote position. While performing the duties of this job, the employee regularly works in a climate-controlled environment. 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. 

Commence is an equal employment opportunity for employer. All personnel processes are merit-based and applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military and veteran status or any other characteristic protected by applicable law.  

Commence.AI is committed to providing equal employment opportunities to all applicants, including individuals with disabilities. If you require reasonable accommodation to participate in the application process due to a disability, please contact Human Resources at (757) 306-4920 or [email protected]. 

Please note that unless you are requesting an accommodation, all applications must be submitted through our online application system.