We are seeking a passionate and experienced Subject Matter Expert (SME) with strong hands-on expertise in one or more of the following areas:

Specialty Expertise: Candidates must have proficiency in coding and billing for one or more of the following specialties:

Key Responsibilities:

Identify, interpret, develop, and implement concepts to detect incorrect healthcare payments through regulatory research, industry expertise, and data analysis.
Analyst to support managing 1-2 medical reimbursement payment policies end-to-end.
Manager and above to manage 2-3 medical reimbursement payment policies end-to-end.
Develop and maintain coding guidelines, Medicare/Medicaid edits, and reimbursement frameworks.
Analyze medical reimbursement methodologies, including policy rules and edits.
Synthesize complex clinical and coding guidelines into actionable business logics.
Ensure compliance and update rules according to the latest industry standards.
Leverage expertise in medical coding, healthcare claims processing, and industry standards to support the development of clinical coding policies and edits.
Operate independently as an individual contributor.

Requirements:

Strong domain expertise in denials logic across Payment Integrity, Revenue Integrity and Denials Management.
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):

Certification Requirements:

Must hold any of the following certifications: CPC, CEMC, CEDC, 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:

Experience in Payment Integrity Content/Research, Denial Management, or Medical Coding.
3+ years experience for Analyst.
5+ years experience for TL.
10+ Years for Manager.
13+ years for Senior Manager.
Experience in rule requirement gathering, rule development and maintenance and Resolving payer denials.
In-depth knowledge of Reimbursement payment policies, Medical coding Denial Management is required.

Key Skills:

Domain Expertise in US Healthcare Medical Coding, Medical Billing, Payment Integrity,Revenue Cycle Management (RCM), Denials Management.
Codeset Knowledge like CPT/HCPCS, ICD, Modifier, DRG, PCS, etc.
Payment Policies knowledge like Medicare/Medicaid Reimbursement, Payer Payment Policies, NCCI, IOMs, CMS Policies etc.
High proficiency in Microsoft Word and Excel, with adaptability to new platforms.
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:

Benefits:

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