Qualifications:
Education & Certification (one of the following required):
- Bachelor’s or Master’s Degree in Computer Science, Data Science, Information Systems, or related field
- Medical or Life Sciences background (MBBS, BDS, BPT, BAMS, Nursing, Pharmacy, Life Sciences)
Certification Requirements:
- Preferable
- FHIR/HL7, EDI Certification
Specialty Expertise:
Candidates must have proficiency in the following areas:
- Understanding of Revenue Cycle Management (RCM), US healthcare Claims & coding and billing.
- Healthcare Claim Form (Professional – 1500), (Facility – 1450) and EDI maps for ANSI X12 transaction sets.
- Medical Codes: CPT/HCPCS, ICD, DRG, Modifiers etc.
- Provider Data: NPI, Taxonomy Codes across all providers.
- Value sets: Standard value set in US healthcare.
- Data Integrity Validation.
- Data classification Metholodologies.
- Preferable, Clinical Data Exchange – Understanding expertise in healthcare data exchange standards (HL7, FHIR,) and clinical terminologies (SNOMED, LOINC).
Key Skills:
- Data Integration & Data Mapping.
- Healthcare Claims Data Analysis.
- Payment Integrity and Claims Adjudication Domain Knowledge.
- Knowledge of code sets: CPT, HCPCS, ICD, DRG, PCS, Modifiers.
- Understanding of Healthcare Claim Form (Professional – 1500), (Facility – 1450) and EDI maps for ANSI X12 transaction sets.
- Strong proficiency in SQL, Python (Preferable), Microsoft Excel and data analysis tools.
- Strong analytical, critical thinking, and problem-solving skills.
- Excellent written and verbal communication skills.