<p>Position Overview: We are looking for a US Healthcare Data Integration SME to support our Payment Integrity client onboarding and operations in the US Healthcare domain. The role involves comprehensive understanding of EDI, Healthcare Claim Form (Professional - 1500), (Facility - 1450), EDI maps for ANSI X12 transaction sets to claims model, Client claims data mapping, Data specs management, Data transformation, Data integration support, Data integrity validating, Data classification and Managing healthcare data from multiple sources to ensure accurate claims analysis, audit processes, and payment accuracy and support client onboarding.</p><p> </p><p>Specialty Expertise:</p><p>Candidates must have proficiency in the following areas:</p><ul><li>Understanding of Revenue Cycle Management (RCM), US healthcare Claims & coding and billing.</li><li>Healthcare Claim Form (Professional - 1500), (Facility - 1450) and EDI maps for ANSI X12 transaction sets.</li><li>Medical Codes: CPT/HCPCS, ICD, DRG, Modifiers etc.</li><li>Provider Data: NPI, Taxonomy Codes across all providers.</li><li>Value sets: Standard value set in US healthcare.</li><li>Data Integrity Validation.</li><li>Data classification Metholodologies.</li><li>Preferable, Clinical Data Exchange – Understanding expertise in healthcare data exchange standards (HL7, FHIR,) and clinical terminologies (SNOMED, LOINC).</li></ul><p> </p><p>Key Responsibilities:</p><ul><li>EDI and Interoperability Leadership: Serve as the Subject Matter Expert (SME) for Electronic Data Interchange (EDI) and healthcare interoperability. Lead the full Software Development/Implementation/Onboarding Lifecycle (SDLC) for cross-functional projects, including requirements gathering, design, testing, implementation, and post-production support.</li><li>HIPAA X12 Specialization: Specialize in HIPAA-compliant X12 transactions, with a strong focus on the 837 (Healthcare Claim File), to support payment integrity operations, data workflows, and payer-provider or payer-payer data mapping and integration.</li><li>Data Specification Management: Design, develop, and maintain robust data claims model/Data Specification for healthcare claims and payment integrity systems for proof of concepts and Go-live.</li><li>Data Sourcing and Transformation: Integrate data from multiple sources, including claims systems, payer platforms, and external healthcare datasets. Perform essential data mapping, transformation, and validation to ensure data accuracy and consistency.</li><li>Collaboration and Alignment: Partner closely with technical teams, business analysts, and client teams to ensure regulatory compliance, seamless system integration, and process automation. Work with Payment Integrity, Analytics, and Technology teams to support audit and automation initiatives.</li><li>Operational Excellence & Compliance: Monitor ETL processes and troubleshoot integration issues. Ensure strict compliance with HIPAA and data security standards when handling sensitive healthcare data. Act as the primary Data Integration liaison between Client and internal teams, driving timely resolution, system compliance, and stakeholder alignment.</li></ul><p> </p><p>Team Development & Mentorship:</p><ul><li>Trained and mentored junior analysts, supporting team professional development and enhancing performance.</li><li>Developed onboarding guides and mentoring programs to support team expansion and knowledge retention.</li><li>Co-develop automated tools with IT to correct transaction errors in real-time, eliminating multi-week delays.</li><li>Collaborated with developers and cross-functional teams to enhance workflow efficiency and optimize system integration.</li></ul><p> </p><p>Client Communication: Data Integration</p><ul><li>Communicate effectively with clients to address and resolve data-related queries independently.</li><li>Analyze and interpret client-reported data issues and provide appropriate solutions.</li><li>Assist clients in ensuring smooth and accurate data integration processes.</li><li>Proactively coordinate with clients to clarify requirements and maintain efficient data workflows.</li></ul><p> </p><p>Requirements:</p><ul><li>Strong understanding of US Healthcare data and claims processing workflows.</li><li>Experience working with healthcare claims datasets and payer systems.</li><li>ANSI X12 transaction sets.</li><li>Claims Model mapping (EDI to Claims Model).</li><li>Understanding of medical coding systems including CPT, HCPCS, ICD, and modifiers.</li><li>Familiarity with dataset policies and rules such as Medicare and Medicaid guidelines, preferable.</li><li>Familiarity of standard healthcare value set, schema etc.</li><li>Experience in data mapping, transformation logic, and integration documentation.</li><li>Ability to analyze data requirements and translate them into data or business rules.</li><li>Strong attention to data accuracy, consistency, and validation.</li><li>Ability to collaborate effectively with cross-functional teams in a fast-paced environment.</li><li>Strong analytical and problem-solving skills.</li></ul><p>Qualifications:</p><p>Education & Certification (one of the following required):</p><ul><li>Medical or Life Sciences background (MBBS, BDS, BPT, BAMS, Nursing, Pharmacy, Life Sciences)</li></ul><p>Certification Requirements:</p><ul><li>Preferable:<ul><li>FHIR/HL7, EDI Certification</li><li>Certified Health Data Analyst (CHDA)</li></ul></li></ul><p>Experience:</p><ul><li>Experience in US Healthcare Data Integration (SME), US Healthcare Data Analysis with deep understanding of Claims model, EDI 837, X12, US healthcare Codesets and datasets.</li></ul><p>Key Skills:.</p><ul><li>Healthcare Claims Data Analysis.</li><li>Payment Integrity and Claims Adjudication Domain Knowledge.</li><li>Knowledge of code sets: CPT, HCPCS, ICD, DRG, PCS, Modifiers.</li><li>Understanding of Healthcare Claim Form (Professional - 1500), (Facility - 1450) and EDI maps for ANSI X12 transaction sets.</li></ul><p> </p><p>Work Location: Jayanagar - Bangalore.</p><p>Work Mode: Work from Office.</p><h3>experience</h3>10

Job Summary:<ul><li>Reviews and evaluates hospital outpatient medical record documentation to assign, sequence, edit and/or validate the appropriate ICD-10-CM and HCPCS/CPT codes. Perform coding and/or code validation across multiple entities. Applies all appropriate coding guidelines and criteria for code selections.Adheres to Company and HSC Coding Compliance policies and procedures for the assignment of complete, accurate, timely, and consistent codes for diagnoses and procedure.</li><li>Supervisor: Coding Manager</li><li>Supervises: None</li></ul>Duties (included but are not limited to):<br />> Using ICD-10-CM and/or HCPCS/CPT, assigns, validates, and/or edits codes for the following patient types:> Emergency room (ED)> Recurring (RCR) excluding Wound Care and Cardiac Cath, and<br />> Clinical (CLI) records<br />> Provider Office Visit (POV)<br />>  Assigns, validates, and/or edits the ED E/M levels, and enters and/or validates charges for ED,OB ED and/or observation (OBV) infusions and/or injections.<br />> Assigns, validates, and/or edits procedure categories and modifiers.<br />> Maintains or exceeds established productivity standards.<br />> Maintains or exceeds established accuracy standards.<br />> Reviews all official data quality standards, coding guidelines, Company policies and procedures, and clinical/medical resources to assure coding knowledge and skills remain current.> Meets all educational requirements as stated in current Company and HSC policies.<br />> Utilizes the complete medical record documentation in code assignment, validation, and/or editing of codes. 2 Job Description:<br />> Follows all applicable coding guidance in assigning, sequencing, validation, and/or editing of codes.<br />> Initiates, validates, and/or edits physician queries in compliance with Company and HSC policy when appropriate<br />>  As needed, may periodically be asked to perform Coding Account Resolution Specialist I (CARSI) duties.<br />> Practices and adheres to the “Code of Conduct” philosophy and “Mission and Value Statement”.<br />> Other duties as assigned.<h3>experience</h3>10

• Responsible for HSC coding operations and clinical documentation improvement operations (as applicable), ensuring timeliness, accuracy, completeness, consistency, compliance and standards fulfillment as defined in HSC Service Level Agreements (SLAs)<br />• Contributes to the development of strategic direction of HIM.<br />• Coaches and provides overall guidance to the HSC coding team to resolve internal and external issues; help resolve dysfunctional behavior within functional area(s); discipline and counsel staff as necessary<br />• Monitors HIM coding performance according to productivity and quality standards as defined in job descriptions and SLAs<br />• Manages and motivates HSC coding and clinical documentation improvement operations (as applicable) staff<br />• Assists in the development and management of strategy, specific goals, objectives, budgets and performance standards for the HSC • Proactively manages, including corresponding communications and escalation paths, significant issues in HIM coding processes (e.g., coding backlogs, HIM coding delays, abstracting backlogs, and data discrepancies), status of projects, barriers and successes Identifies and implements process improvements to lower costs and improve service to facility and various HSC stakeholders/customers<br />• Routinely meets with the SSC Billing Director, Operations Director, HIM Document Imaging Manager and facility HIM Directors to proactively manage A/R (e.g., uncoded accounts, unbilled accounts, rebills)• Stays abreast of regulatory requirements and company compliance policies, ensuring compliance and timely staff education and training<br />• Monitors overall market trends (e.g., physician documentation, record receipt, data request types, coding quality) and communicates to SSC team, HSC team, Facility team and others as appropriate<br />• Provides leadership to coding management team regarding monthly trending analysis of HSC coding performance including weekly and monthly A/R reports<br />• Provides leadership to coding management team regarding abstracting, coding quality and data requests including weekly and monthly reports<br />• Oversees HIM coding personnel, providing recommendations for hiring, promotion, salary adjustment and personnel action where appropriate<br />• Responsible for overseeing performance review process for all direct and indirect reports • Responsible for ensuring employee work schedules sufficiently meet those requirements as established by the HSC Leadership team and through executed SLA’s<br />• Oversees training and education for HSC coding staff<br />• Assists SSD HIM staff in company-wide initiatives such as the development of operational models and education programs<br />• Assumes a lead role for innovation, knowledge sharing and leading practices identification within the HSC and among peer group<br />• Promptly reports issues or trends to the appropriate member of the HSC Leadership team, or other appropriate party<br />• Stays abreast of regulatory requirements and company compliance policies, ensuring timely staff education<br />• Reviews all official data quality standards, coding guidelines, Company policies and procedures, and clinical/medical resources to assure coding knowledge and skills remain current<br />• CaseMix Index Analytical skills – the ability to analyze tends in CMI and determine root cause and address as appropriate<h3>experience</h3>15