We are seeking a passionate and experienced Subject Matter Expert (SME) with strong hands-on expertise in one or more of the following areas:
- Payment Integrity - Understanding of CMS1450 claim form.
- Clinical Coding Analyst - Medical Record Review For Inpatient Records.
- Content Development.
- Payment Integrity Data mining.
- Medical Coding - Inpatient Coding (MS DRG/APR DRG).
- Denials Management - Specifically inpatient.
- DRG validation.
Specialty Expertise: Candidates must have proficiency in coding and billing for one or more of the following specialties:
- Inpatient Coding (MS DRG/APR DRG).
- Clinical Validation (Inpatient Claims).
- Coding Validation (Inpatient Claims).
- Proficient in the ICD-10-CM guidelines.
- Review of denials and appeals related to facility claim form (CMS1450).
- Inpatient facility guidelines (UHDDS).
- Creation of algorithms to select the targeted claims for DRG review.
Key Responsibilities:
- Identify, interpret, develop, and implement concepts to detect incorrect healthcare payments through regulatory research, industry expertise, and data analysis.
- Analyzing inpatient claims data to identify potential errors or inconsistencies.
- 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.
- Familiarity with AI tools and prompt engineering to support medical content development, automation of policy logic, and Concept generation
o Design and optimize prompts for large language models (LLMs) to generate accurate and clinically relevant medical content.
o Experience in utilize AI tools (e.g., Gemini, NotebookLLM, ChatGPT, Claude, Perplexity, Grok, Bard, or custom LLMs) to assist in ideation, content creation, review, summarization, and validation.
Requirements:
- Strong domain expertise in denials logic across Payment Integrity, and Denials Management.
- Solid understanding of medical coding & billing methodologies and guidelines, coding conventions, including DRG, PCS, ICD, LCD/NCD, CPT, Facility related guidelines such as IPPS, SNF, Hospice.
- 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).
- Bachelor of Science in Nursing.
- Pharmacist Degree (B.Pharm, M.Pharm or PharmD).
- Life science Degree (Microbiology, Biochemistry etc).
- Other Bachelor’s Degree with relevant experience.
Certification Requirements:
- Must hold any of the following certifications: CIC, CPC, CPMA, CCS or any specialty certifications from AHIMA or AAPC.
- Additional weightage will be given for AAPC specialty coding certifications CIC.
- 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.
- Experience in rule requirement gathering, rule development and maintenance and Resolving payer denials and appeals.
- 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 ICD, DRG, PCS, Revenue Codes, CPT/HCPCS 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:
- 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.