Position Overview:
This role focuses on developing clinical content, payment integrity rules, and code edit solutions. The Clinical Content Specialist will translate clinical guidelines and payer policies into business logic, algorithms, and rule frameworks for automated claims validation.
Specialty Expertise:
Payment Integrity
Clinical Coding & Policy Development
Claims Prepayment Review
Data Mining & Content Development
Key Responsibilities:
Develop and maintain payment integrity rules, edits, and policies
Design clinical logic & algorithms for claims validation
Translate CMS guidelines → business rules
Build code edit solutions to detect incorrect payments
Conduct research on medical policies and reimbursement methodologies
Enhance and maintain policy libraries and rule frameworks
Support semi-automated claims review systems
Requirements:
Strong experience in Payment Integrity / Clinical Content / Policy building
Ability to convert clinical guidelines into logical rules
Knowledge of CMS policies, payer guidelines, and coding standards
Strong analytical and problem-solving mindset
- Solid understanding of medical coding & billing methodologies and guidelines, including CPT, ICD, LCD/NCD, PTP, NCCI, edits, modifiers, Medicare Physician fee schedule, and coding conventions.
- Proficiency in data collection, analysis, and deriving actionable insights from CMS medical policies, Medicaid Provider Manuals and other Medical publications.
- Translate industry references into actionable business logic to support new rules and policy enhancements.
- Strong understanding of claim forms like UB-04/CMS 1450 and CMS 1500
- Collaborate effectively across teams while managing multiple priorities
- Ability to thrive in a fast-paced, dynamic environment with minimal supervision.
- Demonstrated mindset for continuous learning and improvement and apply insights to policy development, refinement and maintenance.
- Strong stakeholder management, interpersonal, and leadership skills.
- Solution-focused, motivated, entrepreneurial spirit with a strong sense of ownership.
- Clear and effective communication.
- Strong attention to accuracy and detail in all deliverables
Qualifications
Education & Certification (one of the following required):
- Medical Degree (e.g., MBBS, BDS, BPT, BAMS etc)
- Nursing: Bachelor/Master of Science in Nursing
- Pharmacist Degree (B.Pharm, M.Pharm or PharmD)
- Life Science -Bachelor/Master
Certification Requirements:
- Must hold any of the following certifications: CPC, CPMA, COC, CIC, CPC-P, CCS or any specialty certifications from AHIMA or AAPC.
- Additional weightage will be given for AAPC specialty coding certifications.
- Lean Six Sigma certification and practical application experience are preferred.
Experience:
- 3+ years experience for Analyst
- 5+ years experience for TL
- 10+ Years for Manager
- 13+ years for Senior Manager
- Experience in policy development, rule engines, or PI companies
Key Skills:
- Payment Integrity domain knowledge
- Clinical policy & content development
- CMS / Medicare / Medicaid guidelines
- Code edit logic (NCCI, LCD/NCD)
- Strong analytical & interpretation skills
- Excellent verbal & written communication skills.
- Excellent Interpretation and articulation skills
- Strong analytical, critical thinking, and problem-solving skills
- Willingness to learn new products and tools
Work Details:
- Location: Jayanagar, Bangalore
- Mode: Work from Office
Benefits:
- Best-in-class compensation
- Health insurance for Family
- Personal Accident Insurance
- Friendly and Flexible Leave Policy
- Certification and Course Reimbursement
- Medical Coding CEUs and Membership Renewals
- Health checkup
- And many more!
