Clinical Content Specialist (Payment Integrity)
CoverSelf · Bengaluru · onsite · Posted today
Not disclosed1–3 yrsfulltimeSourced from
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About this role
About CoverSelf
CoverSelf empowers US healthcare payers with a truly next-generation, cloud-native, holistic, and customizable platform designed to prevent and adapt to the ever-evolving inaccuracies in healthcare claims and payments. By reducing complexity and administrative costs, we offer a unified, healthcare-dedicated platform backed by top VCs like BeeNext, 3One4 Capital, and Z21 Ventures.
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 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
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
Education & Certification (one of the following required):
At CoverSelf, we are building a global workplace where every individual can discover their true potential, passion, and purpose — regardless of background, gender, race, sexual orientation, religion, or ethnicity. We believe a diverse workplace fosters innovation, creativity, and progress for our employees, communities, and business.
CoverSelf empowers US healthcare payers with a truly next-generation, cloud-native, holistic, and customizable platform designed to prevent and adapt to the ever-evolving inaccuracies in healthcare claims and payments. By reducing complexity and administrative costs, we offer a unified, healthcare-dedicated platform backed by top VCs like BeeNext, 3One4 Capital, and Z21 Ventures.
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 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
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 Manuals 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
Education & Certification (one of the following required):
- 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
- 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.
- 1-3 years experience
- Experience in policy development, rule engines, or PI companies
- 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
- Location: Basavanagudi,Bangalore
- Mode: Work from Office
- Best-in-class compensation
- Health insurance for Family
- Personal Accident Insurance
- Friendly and Flexible Leave Policy
- Certification and Course Reimbursement
- Medical Coding CEUs and Membership Renewals
- Health checkup
- And many more!
At CoverSelf, we are building a global workplace where every individual can discover their true potential, passion, and purpose — regardless of background, gender, race, sexual orientation, religion, or ethnicity. We believe a diverse workplace fosters innovation, creativity, and progress for our employees, communities, and business.
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Skills
Clinical policy content developmentCMS Medicare Medicaid guidelinesCode edit logic NCCI LCD NCDPayment Integrity domain knowledgeStrong analytical interpretation skills