Medical Coding SME- Payment Integrity

Shift is the leading AI platform for insurance.  Shift combines generative, agentic, and predictive AI to transform underwriting, claims, and fraud and risk - driving operational efficiency, exceptional customer experiences and measurable business impact.  Trusted by the world's leading insurers, Shift delivers AI when and where it matters most, at scale and with proven results.

Our culture is built on innovation, trust, and a drive to transform the insurance industry through our SaaS platform. We come from more than 50 different countries and cultures and together we are creating the future of insurance.

As part of our US Healthcare Payment Integrity and Customer Success organization, you will leverage deep technical and clinical coding expertise to design, implement, and support payment integrity solutions that improve claim payment accuracy. You will partner with customers, product, and engineering teams to develop actionable edit logic, perform audits, and drive continuous improvement to reduce waste and help customers recover overpayments.

What you’ll do

• Serve as a subject matter expert on claim payment accuracy across pre-pay and post-pay workflows, including claim editing, audits, compliance, and recovery processes.
• Define, validate, and operationalize claim edit logic and payment integrity rules (pre-pay edits, post-pay analytics, recovery workflows) to maximize accuracy and value for customers.
• Perform coding and clinical audits (inpatient, outpatient, professional) validating ICD, CPT, HCPCS, Revenue Codes, APR/DRG, POA, modifiers, and other relevant elements.
• Support customer appeals and clinical/policy reviews by assessing appropriateness of billed services/supplies and recommending commercially reasonable edits or recovery actions.
• Regularly review payer policies and external benchmarks to identify gaps in the edit library; propose and lead development of new edit concepts and remediation plans.
• Collaborate with Product, Data Science, and Engineering on tooling, rule deployment, testing, and troubleshooting; participate in UAT and release activities.
• Manage multiple audits, projects, and customer inquiries with minimal supervision; produce clear, actionable documentation and executive-level summaries.
• Train and advise internal teams and clients on payment integrity best practices, coding nuances, and regulatory considerations.

What you bring

• 5+ years experience in healthcare claims, provider/hospital billing, revenue cycle, or health plan payment integrity.
• 3+ years as a certified medical coder in a payer, provider, or RCM environment.
• Strong working knowledge of Medicare, Medicaid, Medicare Advantage, Part D, TRICARE, commercial payers, and related regulations.
• Demonstrated expertise auditing for coding accuracy and completeness (ICD, CPT, HCPCS, revenue codes, APR/DRG, POA).
• Proven analytical and problem-solving skills, with ability to synthesize data into reliable, business-relevant insights.
• Excellent written and verbal communication skills; able to compose sensitive, non-routine correspondence and present findings to clinical and non-clinical stakeholders.
• Able to manage competing priorities, operate in a fast-paced, start-up environment, and influence cross-functional teams.

Qualifications and core requirements

• Bachelor’s degree in healthcare administration, business, or related field, or equivalent experience (5-10).
• Certified medical coding credentials required (CPC and/or CCS preferred; CCA, CIA, or equivalent acceptable).
• Must be authorized to work in the US without employment sponsorship or restrictions.

To support our permanent, full time employees at every stage of their careers and lives, we provide a competitive total rewards and benefits package. Here are the global benefits we’d like to highlight:

• Flexible remote and hybrid working options
• Competitive Salary and a variable component tied to personal and company performance
• Company equity
• Multiple Learning and Development opportunities, including Focus Fridays, a half-day each month to focus on learning and personal growth
• Generous PTO and paid holidays
• Mental health benefits 
• 2 MAD Days per year (Make A Difference Days for paid volunteering)

Additional benefits may be offered by country - ask your recruiter for more information. Intern and Apprentice position are eligible for some of these benefits - ask your recruiter for more details.

At Shift we strive to be a diverse and inclusive workforce. We welcome applications from and hire people who will contribute to the diversity of our company, without regard to race, color, religion, marital status, age, national or ethnic origin, physical or mental disability, medical condition, pregnancy, genetic information, gender identity or expression, sexual orientation, or other non-merit criteria.

Shift Technology is committed to providing reasonable accommodations for qualified individuals with disabilities in our application and employment process. Should you require accommodation, please email accommodation@shift-technology.com and we will work with you to meet your accessibility needs.

Please be aware of scammers and only trust correspondence that comes from emails ending in "shift-technology.com". We will never do initial outreach to you via Whatsapp/Text/SMS, never ask for banking information or personal identification numbers (ex. Social Security Number) as part of our recruitment process.

Shift Technology does not accept unsolicited CVs from recruiters or employment agencies in response to the Shift Technology Careers page or a Shift Technology social media post. Any unsolicited CVs, including those submitted directly to hiring managers, are deemed to be the property of Shift Technology.