Clinical Content Specialist (Payment Integrity)

Keka Inc.; Bengaluru; Vor Ort; INR 600.000 - 1.200.000; Vollzeit

Benefits dieser Stelle

Best-in-class compensation

Health insurance for Family

Flexible Leave Policy

Certification and Course Reimbursement

Medical Coding CEUs and Membership Ren

And many more!

Zusammenfassung

CoverSelf is seeking a Clinical Content Specialist (Payment Integrity) to translate clinical guidelines into robust business logic for automated claims validation. You will develop and maintain payment integrity rules, edits, and policy frameworks while collaborating with cross-functional teams to improve data-driven outcomes.

The role focuses on policy development, coding standards, and payer guidelines, with responsibilities spanning research, rule design, and system support in a fast-paced

Qualifikationen

• Experience in Payment Integrity or clinical content policy building.
• Ability to translate clinical guidelines into logical rules.
• Knowledge of CMS policies, payer guidelines, and coding standards.

Aufgaben

• Develop and maintain payment integrity rules and edits.
• Design clinical logic and algorithms for claims validation.
• Build code edit solutions to detect incorrect payments.
• Research medical policies and reimbursement methodologies.
• Maintain policy libraries and rule frameworks.
• Support semi-automated claims review systems.

Kenntnisse

Payment integrity

Code edit logic

Analytical skills

Policy development

Stakeholder management

Communication

Adaptability

Ausbildung

Medical Degree

Nursing degree

Pharmacist degree

Life Science degree

Jobbeschreibung

Clinical Content Specialist (Payment Integrity)

1-3

Full-Time

About CoverSelf:

CoverSelf empowers US healthcare payers with a truly next-generation, cloud-native, holistic, and customizable platform designed to prevent and adapt to the ever-evolving inaccuracies in healthcare claims and payments. By reducing complexity and administrative costs, we offer a unified, healthcare-dedicated platform backed by top VCs like BeeNext, 3One4 Capital, and Z21 Ventures.

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 policie

Design clinical logic & algorithms for claims validation

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:

• 1-3 years experience
• Experience in policy development, rule engines, or PI companies

Key Skills:

• Payment Integrity domain knowledge
• Code edit logic (NCCI, LCD/NCD)
• Strong analytical & interpretation skills
• Excellent Interpretation and articulation skills
• Strong analytical, critical thinking, and problem-solving skills
• Willingness to learn new products and tools
• Mode: Work from Office
• Best-in-class compensation
• Health insurance for Family
• Friendly and Flexible Leave Policy
• Certification and Course Reimbursement
• Medical Coding CEUs and Membership Renewals
• And many more!

Our Commitment to Diversity:

At CoverSelf, we are building a global workplace where every individual can discover their true potential, passion, and purpose — regardless of background, gender, race, sexual orientation, religion, or ethnicity. We believe a diverse workplace fosters innovation, creativity, and progress for our employees, communities, and business.