Responsibilities
- Policy Interpretation & Edit Development: Interpret and apply CMS, Medicare, Medicaid, AMA/CPT, NCCI, and other payer policies to define accurate claims editing logic. Translate regulatory and coding guidance into clear, deterministic pre-pay edits, with documented rationale and references. Build and maintain a proprietary library of claims edits aligned to reimbursement rules and industry standards. Identify reimbursement risk areas and policy interpretation gaps and encode them into actionable edit concepts.
- Claims Validation & Analysis: Own the development of high-quality edit specifications, including logic definitions, assumptions, edge cases, and validation criteria. Analyze claims and edit performance data to confirm accuracy, reduce false positives, and prioritize enhancements by impact. Conduct targeted manual claim reviews to validate coding accuracy, reimbursement correctness, and policy alignment.
- Cross-Functional Enablement: Serve as a SME across Medicare, Medicaid, and commercial claims. Partner with product, engineering, and implementation teams to ensure edits are implemented and validated correctly. Clearly document edit logic, policy interpretation, and outcomes to support internal teams and payer stakeholders.
- Governance & Ongoing Maintenance: Proactively monitor regulatory updates, coding changes, and industry guidance to keep edits current and compliant. Ensure all edits are auditable, defensible, and aligned with external policy sources. Consistently meet productivity and quality expectations in a remote, outcomes-driven environment.
Requirements
- 4+ years of experience in authoring claims editing content with either vendors or payers
- Deep expertise in: CMS policies (LCDs, NCDs, fee schedules) NCCI (PTP and MUE) edits, OIG guidance, correct coding methodologies CPT/HCPCS, ICD-10-CM/PCS, modifiers, place of service, and revenue codes
- Strong understanding of claims processing workflows (CMS-1500, UB-04)
Nice to Have
- SQL skills for claims analysis or edit opportunity identification.
- Clinical background (RN, BSN, PharmD, MD, or equivalent)
Benefits
- Work from anywhere in the US!
- Top Medical/Dental/Vision offerings
- FSA/HSA
- Solid PTO program
- Tuition reimbursement
- Competitive salary, 401(k) with company match
- Additional health and wellness benefits and perks
- Flexible and trusting environment where you’ll feel empowered to do your best work
