Clinical Intelligence Specialist

POSITION SUMMARY

This role involves working as a key collaborator in reviewing medical coverage policies converted by the GenAI. The Clinical Intelligence Specialist will use their clinical experience to make sure converted document matches with the medical coverage policies in PDF document. Post manual review, it is very important to make sure converted medical policies into the questionnaire format is available in Clicbank. ClicBank, is ZeOmegas proprietary tool for the content development and management.

Reasonable Accommodations Statement
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.

Job Responsibilities:

• This role is accountable to ensure the converted documents are matching with the source document. Identifies discrepancies, potential quality issues and correct them manually.
• Research and analyse as needed.
• Analyses the medical policies and identifies documentation deficiencies.
• Assigns codes for each answer options in the decision tree.
• Follows coding conventions. Serves as coding consultant.
• Serves as resource and subject matter expert to other coding staff.
• Assists lead or supervisor in orienting, training, and mentoring staff.
• Provides ongoing training to staff as needed.
• Handles special projects as requested.

SKILLS & ABILITIES:

• Education:
  MBBS / MD / foreign medical graduate background, strong English writing, ability to read medical policies, and comfort with clinical documentation.
• Product fit: Can explain policy rules to product managers, QA, engineers, and AI teams; can identify ambiguity, versioning needs, auditability, and human-in-the-loop review points.

Experience:

U.S. payer exposure, Medicare Advantage, Medicaid, Commercial payer, prior authorization, appeals, UM, medical necessity, HEDIS/Stars, risk adjustment, or clinical guidelines.

Must have some experience within a clinical setting and/or as an experience includes clinical research, critical thinking, time management, medical coding.

Computer Skills: Microsoft Office Suite - Word, Excel, PowerPoint, Visio, Teams, Sharepoint, Outlook, OneDrive, NCD , LCD.