Clinical Subject Matter Expert

Summary

Join Integrity Management Services, Inc. (IntegrityM) as a Clinical Subject Matter Expert (SME) and play a vital role in ensuring the clinical validity, policy alignment, and unbiased nature of AI/ML solutions for Operation MedAI. This role blends clinical expertise with technical collaboration to support AI/ML model design, review processes, and stakeholder engagement. You will contribute clinical judgment and regulatory knowledge to shape data-driven tools used in medical review, program integrity, and Medicare Advantage oversight. Key responsibilities include clinical validation, model guidance and development support, bias mitigation, policy and regulatory alignment, and stakeholder collaboration and communication. The ideal candidate possesses an active Registered Nurse (RN) license, significant clinical experience, and expertise in medical claims review and utilization review. Experience with AI/ML model development and healthcare data structures is preferred.

Requirements

• Active Registered Nurse (RN) license with at least an Associate’s degree
• Or, other clinical specialties as needed (e.g. PT, OT, NP)
• Minimum 5 years of clinical experience as a registered nurse
• At least 3 years of experience in review of medical claims or utilization review for coverage, medical necessity, or program integrity purposes
• Demonstrated experience interpreting federal and state healthcare regulations
• Strong written and verbal communication skills
• Experience working in multidisciplinary project environments, especially involving technology or analytics teams

Responsibilities

• Applies clinical expertise in utilization review and validation processes to ensure appropriate coverage and medical necessity determinations
• Reviews AI/ML model outputs and alerts to assess clinical validity in alignment with accepted guidelines
• Validates predicted patterns and outliers to support accurate fraud, waste, and abuse detection
• Contributes clinical input into model training, testing, quality assurance, and ongoing performance monitoring
• Guides the integration of medical logic into model architecture, particularly supervised learning and hybrid models
• Identifies and validates clinical data elements and coding systems (e.g., ICD, CPT, DRG) used in modeling workflows
• Evaluates data and model behavior for evidence of clinical or demographic bias
• Recommends fairness-enhancing techniques to ensure models support equitable outcomes across diverse populations
• Collaborates with client project teams to ensure that AI-driven solutions support policy enforcement and comply with Medicare Part C and CMS regulatory standards
• Interprets federal and state healthcare regulations and incorporates compliance requirements into model design and validation protocols
• Assists in the development of defensible documentation for audits, education, and enforcement actions
• Serves as a liaison between technical teams and clinical stakeholders, ensuring clinical accuracy and relevance in model deployment
• Participates in internal and client-facing meetings, offering subject matter insight on model performance and medical review strategies
• Contributes to the creation of clinical white papers, findings reports, and strategic planning documents

Preferred Qualifications

• Experience with commercial/private insurance, Medicare Advantage (Part C) policy and/or CMS program integrity initiatives
• Prior involvement in AI/ML model development, clinical data analytics, or technology-driven healthcare tools
• Familiarity with healthcare data structures such as claims, EHR, and HEDIS metrics
• Understanding of algorithmic bias and mitigation practices in healthcare modeling