Mode: Hybrid / Onsite
Shift: US hours (as applicable)
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
Tools & Technology
- Advanced proficiency in Microsoft Excel (Pivot Tables, VLOOKUP, INDEX)
- Experience with Jira or similar workflow tools
- SQL and Tableau exposure is a plus
- Familiarity with EHR or claims processing systems preferred