Clinical Policy Specialist

Overview:
The Clinical Policy Specialist is responsible for developing and managing our clinical and coding products, including Itemized Bill Review, DRG Validation, and Outpatient Clinical and Coding Solutions. This role also provides subject matter expertise (SME) support to the clinical organization and clinical innovation team. The ideal candidate will have expertise in healthcare payment methodologies and audit/review criteria to target key claims for review and recovery. Experience in rule and content development, claims recovery, and coding is essential. Experience with Itemized Bill Review (IBR) concepts is preferred.

Key Responsibilities:

• Content Development: Collaborate with Medical Directors and Innovation Teams to develop new clinical and coding products. Create strategies to enhance claim selection processes and contribute to payment integrity for clients.

• Data Analysis and Organization: Leverage data analysis expertise to innovate new ideas and concepts, including developing Itemized Bill Review strategies. Perform research and scoping analysis for coding and clinical targets.

• Claim Selection Methodology: Refine and execute methodologies that improve claim selection strategies, with a focus on inpatient claims.

• Program Performance: Monitor, analyze, and present program performance results to the clinical leadership team. Recommend and implement improvements.

• Enhance Clinical and Coding Solutions: Assist in the enhancement and review of clinical and coding solutions.

• Product Readiness: Work with a cross-functional leadership team to transition clinical and coding concepts from creation to implementation.

• Regulatory Monitoring: Ensure the effectiveness of written rules by staying updated on regulatory changes and adjusting policies as necessary.

• Analytical Problem-Solving: Use analytical skills to identify trends and develop actionable solutions.

• Policy and Process Documentation: Develop departmental policies, processes, and training standards.

• Clinical and Coding Content: Develop content that informs decision-making for Clinical Services, Quality, and Appeals teams.

• SME Support: Maintain expertise in Gainwell's clinical and coding programs, providing SME support to account management, sales, clients, and clinical teams.

• Client and Sales Support: Provide SME support for RFPs. Meet with clients to explain programs, address policy concerns, and develop solutions for potential issues with clinical and coding review programs.

What We're Looking For:

• Registered Nurse with an unrestricted license in the U.S.

• 10+ years of experience reviewing and/or auditing ICD-10 CM/PCS, MS-DRG, APR DRG claims, and proficiency with encoder products. Experience with APC and EAPG is preferred.

• Required: Inpatient Medical Coding Certification (e.g., CCS, CIC, RHIA, RHIT) or other coding certifications (e.g., CPC) with inpatient coding experience. RN with coding credentials is preferred.

• Strong research skills to understand state and federal regulations, clinical policies, and coding guidelines for policy development and implementation.

• Expertise in Itemized Bill Review product development and enhancements.

• Extensive experience with inpatient and outpatient billing and coding audits, providing SME-level support to the clinical organization.

What You Should Expect in This Role:

• Full-time, permanent salaried (W-2) position

• Remote- Monday through Friday work schedule (40 hours per week)

• Opportunities for upward career advancement

• Health benefits (medical, dental, vision) and paid time off starting on day 1

• 401(k) company match and other benefits available shortly after starting

• Company-provided computer

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