Job Description

• Serve as the primary SNF domain expert for the product development team by translating regulatory and clinical requirements into audit rules, workflows and operational processes.
• Validate and refine SNF audit methodology, including medical necessity criteria, documentation standards and coding requirements.
• Define MVP scope, roadmap enhancements and implementation readiness.
• Apply deep knowledge of CMS SNF regulations, PDPM, MDS/RAI, therapy documentation and state Medicaid policies.
• Monitor regulatory updates and recommend product adjustments as needed.
• Define and validate claim selection logic, risk indicators and scoring models.
• Develop and validate end-to-end workflows, including intake, clinical review, provider outreach and appeals.
• Define SLA expectations for turnaround times, provider response windows and internal review cycles.
• Support training for clinical reviewers, auditors and provider engagement teams.
• Define reporting needs for audit outcomes, savings, provider trends and operational KPIs. Partner with analytics to ensure dashboards and reporting tools are accurate and actionable.
• Identify opportunities for continuous improvement based on audit results.
• Serve as SME during product implementation, ensuring all components are ready for deployment.

• 5-10+ years of experience in Skilled Nursing Facility clinical operations, utilization management, payment integrity or audit programs.
• Strong understanding of CMS SNF regulations, PDPM, MDS/RAI, therapy documentation and medical necessity criteria.
• Experience developing or executing clinical audit programs for Medicaid, Medicare and/or commercial payors.
• Familiarity with claims data, coding standards and documentation requirements.
• Ability to translate complex clinical and regulatory concepts into clear operational and product requirements.
• Strong communication, analytical and data comprehension skills.

• RN, PT, OT, SLP or other clinical licensure.
• Experience with payment integrity vendors, health plans or state Medicaid agencies.
• Background in product development or clinical audit solution design.
• Experience developing claims scoring models or working with analytics teams.