Clinical Content Specialist (Payment Integrity)

Coverself Inc.; Bengaluru; On-site; INR 180,000 - 240,000; Full time

Benefits offered by this job

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 Ren

Health checkup

And many more!

Job summary

CoverSelf in Bengaluru seeks a Clinical Content Specialist to turn CMS guidelines and payer policies into business logic, rule engines, and code edits for automated claims validation. You will develop and maintain payment integrity rules, design clinical logic, translate industry guidelines into actionable rules, and support semi-automated review systems.

1–3 years in payment integrity or policy development, familiarity with CPT/ICD, CMS/NCD/LCD, and strong analytical, communication, and

Qualifications

• Convert CMS guidelines into logical rules and business logic.
• Strong knowledge of CMS, payer guidelines, and coding standards.
• Experience in policy development and rule engines.
• Ability to derive actionable insights from medical policies.

Responsibilities

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

Skills

Payment Integrity

Clinical Content

Policy building

CMS policies

Data analysis

CMS guidelines

Attention to detail

Stakeholder management

Education

Medical Degree

Nursing degree

Pharmacist degree

Life Science degree

Tools

UB-04/CMS 1450

CMS 1500

Policy management systems

Job description

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.

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
• Translate CMS guidelines -> business rules
• 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

• 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
• Clinical policy & content development
• CMS / Medicare / Medicaid guidelines
• Code edit logic (NCCI, LCD/NCD)
• Strong analytical & interpretation skills
• 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: Basavanagudi,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
• 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.