Clinical Content Specialist (Payment Integrity & Policy

Angel-and-Genie; Bengaluru; On-site; INR 800,000 - 1,200,000; Full time

Job summary

Angel-and-Genie in Bengaluru, India is seeking a Clinical Content Specialist to develop and maintain clinical content and payment integrity rules. The role involves translating clinical guidelines into automated claims validation logic and conducting research on medical policies.

Ideal candidates will have significant experience in the Payment Integrity domain and relevant medical degrees. A collaborative attitude and strong communication skills are essential.

Qualifications

• 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.

Responsibilities

• Develop and maintain payment integrity rules, edits, and policies.
• Design clinical logic & algorithms for claims validation.
• Build code edit solutions to detect incorrect payments.

Skills

Payment Integrity domain knowledge

Clinical policy & content development

CMS/Medicare/Medicaid guidelines

Strong analytical & interpretation skills

Excellent verbal & written communication skills

Education

Medical Degree (e.g., MBBS, BDS, BPT, BAMS, etc.)

Bachelor/Master of Science in Nursing

Pharmacist Degree (B.Pharm, M.Pharm or PharmD)

Life Science – Bachelor/Master

Job description

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 policies
• Design clinical logic & algorithms for claims validation
• Translate CMS guidelines to 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 Manual, 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

• 3+ years experience for Analyst
• 5+ years experience for TL
• 10+ years for Manager
• 13+ years for Senior Manager
• 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