Underpayments Specialist

Underpayments Specialist

Role

The Underpayments Specialist will play an important role in SmarterDx’s next product launch in the Underpayments space. This role will work closely with Product and Data Science teams to refine and collaborate on strategies that enable our customers to improve clinical quality scores and accurately reflect care delivered through compliant coding. This specialist will bring a creative and clinical view to underpayments detection and assist in defining models, rules, and workflows that drive performance recovering payments

**This role is fully remote within the US**

What You’ll Do

• Partner with Product and Data Science to define and refine underpayment detection logic, using EDI and payments data (e.g., 835/837, remit codes, claim line details).
• Analyze inpatient and outpatient claims and payment data to identify patterns of underpayment, non-compliance with payer contract terms, and revenue leakage.
• Translate payer contracts, reimbursement methodologies, and business rules into clear, machine-actionable logic and workflows.
• Review and validate technology-generated underpayment flags to ensure they are supported by contract terms, billing rules, and claims/EDI data.
• Identify data quality issues or gaps (e.g., missing contract attributes, coding inconsistencies, EDI mapping issues) that limit accurate underpayment identification.
• Collaborate with internal teams to optimize mappings for codes and fields commonly used in underpayment workflows (e.g., DRG, APC, CPT/HCPCS, revenue codes, modifiers, CARC/RARC codes).
• Serve as a subject matter expert on underpayments, payer behavior, and hospital revenue cycle, advising product development on edge cases and nuances in real-world workflows.
• Contribute to product strategy by validating model outputs, suggesting new underpayment scenarios, and helping design user flows that drive adoption and recovery performance for our customers.

What You Bring

• 8+ years of experience hospital or health-system revenue cycle, underpayments, denials, contract management, or payer reimbursement integrity 
• Hands-on experience working with EDI and payments data (e.g., 835/837, remittance advice, claim files) in the context of reimbursement or analytics.
• Strong understanding of payer reimbursement methodologies, such as DRG, APC, per diem, case rate, and fee-for-service.
• Experience interpreting payer contracts, payment policies, and billing rules and applying them to real claims data.
• Familiarity with UB-04 and/or CMS-1500, revenue codes, CPT/HCPCS, modifiers, and common CARC/RARC codes.
• Comfort working with data and collaborating with technical teams; ability to clearly explain requirements and logic to Product, Data Science, and Engineering partners.
• Previous experience, or strong interest, in advising or consulting for healthcare technology companies, with a passion for leveraging AI and analytics to support revenue integrity performance.

Must Haves

• Proven experience working with inpatient and outpatient claims and payments data.
• Demonstrated ability to translate complex payer rules and contracts into operational workflows or system logic.
• Ability to grow and contribute across multiple functions as the role and product evolve in a fast-paced startup environment.

Nice To Haves

• Prior advising or consulting experience with healthcare technology companies.
• Familiarity with CMS payment rules, payer policy updates, and regulatory guidance that impact reimbursement.
• Experience collaborating with or leading teams focused on underpayment recovery, denials, or reimbursement optimization.

• $115k - $140k base + equity

#LI-Remote