Clinical Analyst

Milliman Ireland; Hinoba-an; On-site; PHP 600,000 - 800,000; Full time

Job summary

Milliman Ireland is seeking a Clinical Coding & Claims Analytics Consultant with experience in clinical coding, medical claims analysis, reimbursement methodologies, and healthcare consulting.

The role will support the development of clinical rules for claims adjudication, perform coding and reimbursement analytics, contribute to DRG and grouper initiatives, and deliver consulting projects for healthcare payers, providers, and health system stakeholders.

Qualifications

• Bachelor's degree in a healthcare field and HIMAA certification or equivalent.
• 2–4 years experience in clinical coding, claims analytics, or reimbursement analysis.
• Strong understanding of coding standards and medical claims lifecycle.

Responsibilities

• Develop clinical rules for medical claims adjudication and payment integrity.
• Perform coding reviews, mapping across ICD-10-AM, ACHI, SBS and AR-DRG systems.
• Analyze claims data to identify discrepancies and reimbursement opportunities.
• Contribute to DRG grouper validation and fee schedule development.
• Prepare analytical reports and client deliverables across multiple workstreams.

Skills

Analytical thinking

Problem solving

Documentation

Excel proficiency

Education

Bachelor's degree in Medicine or related healthcare discipline

HIMAA certification

Tools

ICD-10-AM, ACHI, SBS, AR-DRG knowledge

Job description

Independent for over 75 years, Milliman delivers market-leading services and solutions to clients worldwide. Today, we are helping companies take on some of the world’s most critical and complex issues, including retirement funding and healthcare financing, risk management and regulatory compliance, data analytics and business transformation. Through a team of professionals ranging from actuaries to clinicians, technology specialists to plan administrators, we offer unparalleled expertise in employee benefits, investment consulting, healthcare, life insurance, and financial services, and property and casualty insurance.

Role Summary

We are seeking a Clinical Coding & Claims Analytics Consultant with experience in clinical coding, medical claims analysis, reimbursement methodologies, and healthcare consulting. The role will support the development of clinical rules for claims adjudication, conduct coding and reimbursement analytics, contribute to DRG and grouper initiatives, and deliver consulting projects for healthcare payers, providers, and health system stakeholders.

The ideal candidate should possess strong knowledge of clinical coding systems, health insurance operations, claims adjudication workflows, reimbursement frameworks, and healthcare data analytics, with exposure to healthcare markets across the Middle East.

Key Responsibilities

Clinical Rules & Product Development

• Support the design, development, testing, and validation of clinical rules used in medical claims adjudication and payment integrity programs.
• Define clinical logic for medical necessity review, coding validation, reimbursement controls, benefit interpretation, and claims editing.
• Participate in user acceptance testing (UAT) and validation of clinical rule engines and adjudication systems.

Clinical Coding & Classification

• Perform clinical coding reviews and code mapping across healthcare coding and classification systems - ICD-10-AM, ACHI, SBS and ADRG / AR-DRG
• Ensure coding consistency and compliance with applicable coding standards, reimbursement guidelines, and payer policies.
• Support coding validation exercises, reimbursement reviews, and clinical classification projects.

Claims Analytics & Reimbursement

• Analyze structured and unstructured medical claims data to identify coding discrepancies, billing anomalies, utilization patterns, and reimbursement opportunities.
• Support payment integrity initiatives through identification of inappropriate billing, coding errors, duplicate claims, and reimbursement leakage.
• Contribute to DRG grouper validation, fee schedule development, reimbursement modelling, and healthcare costing initiatives.
• Support consulting projects related to:
• Clinical code mapping
• Claims analytics
• DRG implementation
• Develop analytical reports, presentations, client deliverables, and documentation.
• Participate in stakeholder discussions and support project execution across multiple workstreams.

Data Quality & Insights

• Conduct healthcare data quality assessments and identify opportunities for process improvement.
• Interpret payer policies, reimbursement guidelines, and regulatory requirements relevant to claims adjudication and coding practices.
• Generate actionable insights from claims and clinical data to support decision-making and operational improvements.

Required Qualifications

• Bachelor's degree in Medicine, Dentistry, Nursing, Pharmacy, Life Sciences, Health Information Management, Healthcare Management, or a related healthcare discipline.
• HIMAA certified and working knowledge of coding systems such as ICD-10-AM, ACHI, SBS and AR-DRG.
• 2-4 years of experience in clinical coding, health insurance, claims analytics, healthcare consulting, revenue cycle management, or reimbursement analysis.
• Strong understanding of:
• Clinical coding standards
• Medical claims lifecycle
• Health insurance operations
• Claims adjudication workflows
• Experience performing claims reviews, coding audits, reimbursement analyses.
• Strong analytical, problem-solving, and documentation skills.
• Advanced proficiency in Microsoft Excel or similar analytics tools is preferred.
• Ability to work effectively within multidisciplinary teams and manage multiple project priorities.