Clinical Content Specialist (Payment Integrity)

About the role

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.

What you'll do

• 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

What you need

• 1–3 yrs of experience
• Medical coding
• Research
• MBBS or BDS or B.Pharm or M.Pharm

Good to have

• Six Sigma