Clinical Policy & Claims Analytics Specialist

Color Employer, LLC

Tennessee

Hybrid

USD 90,000 - 130,000

Full time

6 days ago

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Job summary

Lyric is seeking a Clinical Analyst to support development of clinical policies and payment solutions enabling fast, accurate coverage decisions. The role requires deep knowledge of diagnostic testing, IT, payment integrity, and clinical care to drive transparency and automation for health plans, providers, and labs.

Applicants must be legally authorized to work in the U.S. Visa sponsorship is not available.

Qualifications

Bachelor's degree in biology, nursing, health sciences, or a related field
5 years' experience in direct patient care, clinical research, utilization management, payment integrity, revenue cycle management, clinical product development/program management, market access/medical science liaison, or medical writing
Demonstrated technological proficiency with MS Word, MS Excel, JIRA or Monday.com or other project management software

Responsibilities

Apply claims analytics to identify opportunities for coverage criteria and claim edit development
Identify and critically evaluate medical literature as part of evidence-based policy development
Draft, review, and maintain coverage criteria based on characteristics such as age, clinical presentation, and risk factors
Provide written and oral presentations to peers and leadership to obtain consensus on proposed criteria
Recommend and program rules/logic for denial of claims based on the criteria in written policies
Enter clinical content into internal tooling and databases
Provide clinical content support to customers in collaboration with Customer Operations as needed