Clinical Policy Specialist- Remote in US

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

Summary

The Clinical Policy Specialist is responsible for the development and performance of our clinical solutions. This role requires expertise in healthcare payment methodologies, clinical policy interpretation, and audit criteria to target key claims for review and recovery. Proven experience in rule and content creation, claims data analysis, claims recovery, and coding expertise is essential. Key responsibilities include clinical policy research, regulatory monitoring, developing new content, analyzing data to support concept development, tracking performance, providing implementation and client support, conducting research, and reviewing claims data as needed. This role requires an expert in clinical areas including payment integrity, with the ability to lead the development of new solutions to drive the success of our clinical solutions and ensure optimal performance.

Your role in our mission

• Content Development: Work in conjunction with the Medical Directors and Innovation Teams to develop new clinical and coding products. Develop innovative strategies to enhance audit strategy, claim selection processes, and significantly contribute to payment integrity for our clients.
• Data Analysis and Organization: Leverage data analysis expertise and strong organizational skills to innovate new ideas and solutions, including the development of Itemized Bill Review. Perform research and conduct scoping analysis for the development of coding, clinical targets, and edits.
• Claim Selection Methodology: Utilize a comprehensive understanding of claim selection methods to refine and execute methodologies that enhance claim selection strategies, particularly focused on inpatient claims.
• Program Performance: Monitor and analyze current and new concepts and track performance. Present results to the clinical leadership team. Recommend and implement program changes to improve performance.
• Enhance Clinical and Coding Solutions: Utilize expertise to assist in the enhancement and review of clinical and coding solutions.
• Product Readiness: Work with multi-disciplinary teams of data analytics leaders, operations leads, product leaders, and auditors to bring clinical and coding concepts from creation to implementation.
• Regulatory Monitoring: Assess and adjust policies and rules by monitoring their effectiveness, keeping up with regulatory updates, and making necessary changes. Monitor and research changes in clinical/coding guidelines and regulations and determine their impact on Gainwell programs.
• Policy and Process Documentation: Develop departmental policies, processes, and training standards. Provide internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances.
• Research and Special Projects: Assist with research, special projects, and ad hoc claim reviews as needed.
• Clinical and Coding Content: Develop clinical and coding content that will drive decision-making and documentation for the Clinical Services, Quality, and Appeals teams. Develop training and education, and work with clinical teams to ensure that coding content standards are well understood by all levels of the organization.
• SME Support: Maintain expertise in current Gainwell clinical and coding program processes, workflows, and results. Provide primary SME support regarding clinical policy, clinical, and coding review programs and processes to account management, sales, clients, and clinical teams.
• Client and Sales Support: Provide RFP SME Support. Meet with clients to explain programs and processes, discuss policy concerns, identify issues, and develop proactive solutions to problems that clients may be having or anticipate having with Gainwell clinical and coding review programs.

What we're looking for

• Bachelor's degree (health administration, business, nursing) or 10 years of experience in lieu of education
• Registered Nurse with an active and unrestricted license
• Leadership and policy research experience preferred
• Deep experience with principles of coding audit, utilization review, and payment integrity programs
• Experience with clinical ideation and new clinical content development
• 5+ years of experience with healthcare policy, Medicare guidelines, and State regulation research and interpretation.
• Equivalent experience of 3+ years in claims auditing and recovery auditing
• Ability to research State and Federal regulations, clinical policies, and coding guidelines to develop and implement policies, clinical/coding resources, and tools to support Gainwell’s Clinical Claim Review products.
• Independently perform research and data analysis leveraging claims data to develop new audit strategies, solutions, edits, and targets.

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The pay range for this position is $80,600.00 - $115,200.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies is committed to a diverse, equitable, and inclusive workplace. We are proud to be an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.