Senior Consultant - Clinical Coding

enGen Global; Hyderabad, Chennai; On-site; INR 2,500,000 - 4,500,000; Full time

Job summary

enGen Global is seeking a Senior Consultant for Clinical Coding and Payment Integrity with 10+ years in healthcare claims. The role focuses on auditing, coding accuracy, and preventing revenue leakage across pre- and post-payment processes.

You will collaborate with claims, clinical, and technology teams to refine rules, validate outcomes, and support modernization efforts in a regulated environment.

Qualifications

• 10+ years in healthcare claims, clinical/medical coding, payment integrity, or claims auditing.
• Expertise in ICD-10-CM/PCS, CPT, HCPCS, NDC and related coding guidelines.
• Ability to translate policies into clear business rules and test scenarios.

Responsibilities

• Provide subject matter expertise in healthcare claims coding and payment integrity.
• Audit claims and documentation for coding accuracy and alignment with guidelines.
• Analyze claims data to identify discrepancies and opportunities for improvement.
• Collaborate with cross-functional teams to resolve complex coding questions.
• Develop and validate rules, edits, and validation criteria for automated reviews.
• Mentor analysts on coding and payment integrity concepts.

Skills

ICD-10-CM/PCS

CPT/HCPCS

NDC

Revenue codes

Claims auditing

Data analysis

HIPAA compliance

PHI/PII handling

Education

Bachelor's degree in IT or related field

Tools

Facets

HealthRules

NASCO

OSCAR

Job description

Job Description

Senior Consultant -Clinical Coding, Claims Coding Payment Integrity Consultant

Experience 10+ years of overall experience in healthcare claims, clinical/medical coding, payment integrity, claims auditing.

ROLE OVERVIEW

We are seeking a highly analytical and experienced Clinical Coding Payment Integrity Consultant with over 10 years of experience in the healthcare industry. The ideal candidate will serve as a subject matter expert, responsible for ensuring the accuracy and integrity of clinical coding and claims processing to prevent revenue leakage and ensure compliance. This role involves conducting detailed audits, analyzing complex claims data, identifying payment discrepancies, and providing expert guidance to internal teams and external partners. You will play a critical role in upholding our ficial stewardship and operational excellence.

KEY RESPONSIBILITIES

• Provide subject matter expertise in healthcare claims coding, clinical coding, reimbursement, and payment integrity, reviewing claim and clinical documentation to assess coding accuracy, completeness, and alignment with applicable coding guidelines, reimbursement policies, and payer requirements.
• Analyze diagnosis, procedure, drug, revenue, and other claim coding using industry-standard code sets such as ICD-10-CM/PCS, CPT, HCPCS, and NDC.
• Support pre-claim, pre-payment, and post-payment integrity activities focused on identifying and preventing billing and coding errors, overpayments, duplicate or inappropriate payments, and other payment inaccuracies.
• Assess claims-processing and payment-integrity rules, edits, and workflows, identifying gaps and recommending improvements that strengthen payment accuracy and consistent adjudication.
• Interpret medical, reimbursement, and payment policies and translate them into clear business rules, coding requirements, validation criteria, and test scenarios.
• Partner with claims, clinical, provider, benefit, product, and technology teams to resolve complex coding, reimbursement, and adjudication questions.
• Support analysis of legacy claims and coding rules during modernization efforts, including rule clarification, mapping, rationalization, and validation of expected outcomes.
• Perform root-cause analysis of coding and payment discrepancies, documenting findings, business rationale, corrective actions, and prevention opportunities.
• Validate payment-integrity concepts and audit logic using representative claims, medical documentation, and expected payment outcomes.
• Collaborate with analytics and technology teams to define clinically and operationally meaningful features, rules, and validation criteria for automated claims-review and payment-integrity solutions, while providing technical and domain leadership to mentor analysts and team members on claims coding and payment-integrity concepts.

MANDATORY TECHNICAL / DOMAIN SKILLS

• Clinical Medical Coding ICD-10-CM/PCS, CPT, HCPCS, NDC, revenue codes and related coding guidelines Interpret common diagnosis, procedure, drug and facility coding and use documented coding requirements to support claim review and rule validation.
• Payment Integrity Pre-claim, pre-pay, post-pay, billing/coding errors and payment accuracy Identify payment-integrity risks and help define audits, edits, validation rules and corrective actions that support accurate payments.
• Claims Auditing Clinical documentation review, coding validation, reimbursement-policy review and audit rationale Perform evidence-based reviews, document findings and maintain defensible rationale and traceability.
• Reimbursement Systems DRG, APC, Fee-for-Service, Value-Based Payments Possess deep knowledge of various provider reimbursement models; analyze and audit payments across different methodologies to ensure accuracy.
• Data Analysis Claims data analysis, discrepancy/root-cause analysis, trends and data-quality validation Analyze claim-level information to identify coding/payment issues, patterns and downstream impacts.
• Compliance Privacy Healthcare compliance, PHI/PII handling, documentation and auditability Apply appropriate controls and documentation practices when working with regulated healthcare and claims information.
• Healthcare Regulations CMS Guidelines, HIPAA Compliance, State-Specific Mandates Ensure all coding and payment activities are fully compliant with federal and state regulations; interpret and apply new regulatory guidance effectively.

DESIRABLE / GOOD-TO-HAVE SKILLS

• Professional medical coding or auditing certification such as CPC, CCS, CIC, COC, CPMA or comparable credential.
• Experience with commercial and/or government healthcare claims and payer payment-integrity programs.
• Knowledge of provider billing, fraud/waste/abuse concepts and pre-payment or post-payment audit operations.
• Experience supporting claims-platform modernization, payment-integrity edit implementation or automation initiatives.
• Familiarity with Facets, HealthEdge HealthRules, NASCO, OSCAR or comparable healthcare claims-administration platforms.
• Exposure to analytics, AI/ML-assisted claims review or automated coding/audit solutions, with appropriate clinical and human validation.

EDUCATION

Bachelors degree in Information Technology or a related discipline is preferred. Relevant healthcare coding, claims or payment-integrity experience and professional certifications may be considered in line with organizational hiring policy