Payment Integrity Principal

About Lyric

Lyric is an AI-first, platform-based healthcare technology company, committed to simplifying the business of care by preventing inaccurate payments and reducing overall waste in the healthcare ecosystem. This enables more efficient use of resources to reduce the cost of care for payers, providers, and patients. Lyric, formerly ClaimsXten, is a market leader with 35 years of pre-pay editing expertise, dedicated teams, and top technology. Lyric is proud to be recognized as 2025 Best in KLAS for Pre-Payment Accuracy and Integrity, is HI-TRUST and SOC2 certified, and a recipient of the 2025 CandE Award for Candidate Experience. Interested in shaping the future of healthcare with AI? Explore opportunities at lyric.ai/careers and drive innovation with #YouToThePowerOfAI.

Applicants must already be legally authorized to work in the U.S. Visa sponsorship/sponsorship assumption and other immigration support are not available for this position.

Role Overview: Payment Integrity Principal

The Payment Integrity Principal serves as senior authority for system-level payment integrity strategy, logic, and enablement across Lyric’s platform. This role operates above transactional execution and is accountable for how domain expertise (Coding Review (CR), Coordination of Benefits (COB) and/or Data Mining (DM)) is translated into scalable, automated, and future-ready solutions across rules, workflows, analytics, and AI-driven capabilities.

The Principal ensures that payment integrity logic, platform capabilities, workflow orchestration, and automation strategies work cohesively to deliver accurate, defensible, and scalable outcomes—today and as the platform evolves. This role partners deeply with product, engineering, analytics, and operations to design, govern, and continuously improve: rule logic and configuration, workflow orchestration, automation (rules engines, bots, agents), machine learning, and AI-assisted decisioning.

The Principal has end-to-end accountability for ensuring that payment integrity solutions are technically sound, operationally viable, and strategically aligned with Lyric’s future-state platform vision.

Essential Job Responsibilities & Key Performance Outcomes

Platform, Technology & Automation Ownership

• Serve as a senior business owner for how program domains (i.e., CR, COB, DM) logic is implemented across Lyric’s platform, including rules engines, workflow orchestration, analytics pipelines, and automation frameworks.
• Ensure that basic rule logic, advanced automation, and AI-driven capabilities work together cohesively to support scalable payment integrity outcomes.
• Define how domain-specific logic should be: automated through configurable rules, operationalized via workflow orchestration, augmented through bots, agents, or decision automation, enhanced through machine learning or AI where appropriate.
• Partner with product and engineering to translate domain expertise into clear technical requirements for platform capabilities, influence platform roadmap decisions related to payment integrity enablement, ensure new tooling or automation aligns with real-world payment behavior and operational constraints.
• Act as a steward of technical debt management, ensuring logic, rules, and workflows remain maintainable, explainable, and auditable as the platform scales.

Enterprise Strategy and Domain Expertise

• Serve as a domain specific senior subject matter expert supporting enterprise initiatives, rule development, and analytical strategy.
• Identify gaps where manual effort, inconsistency, or false positives indicate the need for automation, logic refinement, or AI augmentation.
• Ensure domain strategies align with current operational reality and future platform direction.
• Translate coding and reimbursement research into clear, detailed, and actionable logic that supports the development or refinement of claim editing rules and payment integrity policies.
• Define precise triggering criteria, conditions, hierarchies, and exclusions required for accurate rule configuration and downstream system implementation.
• Partner with rule writers, configuration analysts, and technical teams to ensure logic intent is preserved through build, testing, and deployment.
• Maintain working knowledge of existing payment integrity rules and logic to strengthen cohesion, reduce redundancy, and improve overall rule performance.

Analytical contribution and research

• Analyze claims data to identify patterns, inconsistencies, false positives, and emerging payment risk areas.
• Conduct in-depth research on complex coding, reimbursement, and billing topics to support new content development or policy interpretation.
• Continuously evaluates market trends, regulatory changes, emerging technologies, and competitor capabilities to identify gaps, risks, and opportunities that inform improvements.
• Use findings to challenge assumptions, refine logic, and ensure proposed solutions align with real-world billing practices, payment policies, and coding standards.

Cross-functional collaboration and communication

• Serve as a thought leader and partner with analytics, product, engineering, policy, and operational teams to advance payment integrity initiatives.
• Translate complex domain and technical concepts into clear guidance for diverse audiences.
• Support special projects that advance payment integrity maturity, scalability, or innovation.

Key Performance Outcomes

• Rule logic effectiveness measured by % reduction in false positives attributable to Principal-led rule, workflow, or automation changes.
• Automation & scale enablement ratio measured by % of identified payment integrity opportunities that are automated (rules, workflows, bots, or AI-assisted) vs. manual.
• Net improvement in product performance metrics driven by principal-led initiatives (i.e., prevented overpayments, increased overpayment findings, improved quality, speed).
• Effective cycle times for design to deployment as measured by median time (days) from logic changes, UI enhancements, workflow changes approval to production deployment for Principal-sponsored initiatives.

Required Qualifications

• Bachelor’s degree in healthcare, business, information systems, data analytics, or a related field, or an equivalent combination of education and relevant experience.
• Active professional credential aligned to domain specialization, such as: Coding Review (CR): CPC, CCS, CCS-P, RHIA with professional, inpatient and outpatient facility coding expertise, Coordination of Benefits (COB): Deep COB/TPL expertise with demonstrated mastery of primacy and eligibility logic, Data Mining (DM): Advanced payment integrity auditing experience with strong reimbursement and contract interpretation background.
• 12+ years of progressive experience in healthcare payment integrity, including Coding Review, Coordination of Benefits, Data Mining, or closely related disciplines.
• 7+ years of advanced experience analyzing, auditing, or designing solutions to identify and prevent improper payments within a health plan, payment integrity vendor, or payer-side environment.
• Proven experience translating domain expertise into scalable logic, including rule design and configuration, workflow orchestration, decision logic or automation frameworks.
• Strong analytical skills with the ability to analyze large claims datasets, identify trends, inconsistencies, and systemic risk, and validate assumptions against real-world billing behavior.
• Demonstrated experience contributing to or guiding AI-assisted decisioning, machine learning-enabled workflows, advanced analytics or prioritization models, and ability to define guardrails for AI explainability, governance, and human-in-the-loop controls.
• Experience partnering with product and engineering teams to translate business and domain requirements into technical specifications and support build, testing, deployment, and post-release optimization.

Preferred Qualifications

• Advanced technical and analytical skills including advanced proficiency with Microsoft Excel for data analysis, validation, and performance measurement, knowledge of SQL, Boolean logic, or query-based analysis tools, and Experience working with analytics or BI tools to evaluate production performance.
• Experience defining performance metrics, feedback loops, and continuous improvement processes for automated or AI-driven systems and /or familiarity with AI governance frameworks, model monitoring, or explainability standards.
• Experience designing, scaling, or optimizing enterprise-level payment integrity programs.
• Experience identifying and reducing false positives, operational abrasion, or unnecessary manual effort through system design.
• Leadership & Change Enablement; Experience acting as a change agent in evolving or scaling organizations and comfort operating in ambiguity and influencing without authority.

Key skills/competency

• Payment Integrity Strategy
• Coding Review (CR)
• Coordination of Benefits (COB)
• Data Mining (DM)
• AI/Machine Learning
• Workflow Automation
• Claims Data Analysis
• Technical Requirements
• Product Partnership
• Healthcare Technology