Position Overview
The Clinical Analyst / Senior Clinical Analyst will play a key role within the Research and Content function contributing to medical policy research, payment integrity initiatives, claims adjudication support, and quality assurance activities.
This role involves close collaboration with Operations, Product, QA, and Technology teams to ensure accurate, compliant, and efficient healthcare outcomes. The ideal candidate brings a strong clinical background, hands-on exposure to US healthcare payer operations, and a keen interest in policy-driven analytics and automation.
Key Responsibilities
Medical Policy Research & Development
- Research, interpret, and document Medicare and Medicaid policies (state and federal)
- Create, review, and maintain payment integrity / IPU medical policies
- Align policies with CMS guidelines and payer-specific requirements
- Perform conflict reviews and periodic policy audits
Claims & Adjudication Support
- Support medical claim adjudication for high-dollar and low-dollar claims
- Apply knowledge of ICD-10-CM, CPT, HCPCS, and NDC codes
- Review claims for medical necessity, bundling, units, age/gender edits, and reimbursement accuracy
- Support initiatives to reduce denials and improve claims accuracy
Quality Assurance & Compliance
- Conduct quality assurance on policy rules and configurations with high accuracy standards
- Perform UAT / BRAT testing and validate system logic
- Identify issues, conduct root cause analysis, and support resolution
- Ensure compliance with HIPAA, CMS, and state Medicaid regulations
Process Improvement & Automation
- Support process improvement and shift-left initiatives
- Collaborate with Product and Technology teams on automation opportunities
- Participate in workflow optimization to improve SLA and turnaround times
Stakeholder Collaboration & Documentation
- Act as a point of contact for internal teams and client queries
- Participate in knowledge-sharing and training sessions
- Document policies, processes, and operational guidelines
Qualifications
Education
- Bachelor’s degree in one of the following:
- Dental (BDS)
- Medicine / Physiotherapy / Nursing / Allied Health
- Medical coding certification (CPC) is an added advantage
Experience
- 2–8 years of experience in US healthcare operations, analytics, or payment integrity
- Hands-on experience in one or more of the following:
- Medicaid / Medicare research
- Medical policy creation, maintenance, or QA
- Claims adjudication or healthcare analytics
Required Skills
Domain & Functional Skills
- Strong understanding of the US healthcare payer ecosystem
- Knowledge of Medicaid and Medicare reimbursement policies
- Exposure to payment integrity and IPU rule frameworks
- Medical coding knowledge (ICD-10, CPT, HCPCS)
- Policy audits and compliance management