Job
Description
Position Overview: We are seeking a detail-oriented and clinically knowledgeable Clinical Client Policy Data Analyst to join our Clinical Coding Policy team. This role involves the clinical analysis of professional, and facility claims, validation of edit logic, and development of review guidelines aligned with industry standards. The ideal candidate will serve as a subject matter expert in clinical policy interpretation and coding edits and will play a key role in root-cause analysis, edit ideation, and dispute resolution from providers. This role is integral to ensuring that all claims reviewed under clinical coding policy guidelines are accurate, compliant, and consistent with payer policies and national coding standards such as NCCI, AMA, and CMS guidelines. Key Responsibilities: Conduct clinical coding reviews of professional and facility claims routed through the Clinical Coding Policy queue. Perform in-depth research and analysis of complex coding scenarios and edit performance. Collaborate with cross-functional teams, including resolution analysts, IT, and leadership, to improve review logic and workflow. Analyze provider disputes related to accepted coding edits and support decisions with clinical and coding evidence. Maintain up-to-date documentation of review processes, guidelines, and clinical validation standards. Assist in the creation and maintenance of job aids to ensure consistency and efficiency across validation processes. Submit and support IT enhancement requests to improve reporting and claims analysis tools. Ensure alignment with payer reimbursement policies, federal/state regulations, and standard coding references (NCCI, AMA, CMS). Identify root causes of edit performance issues and provide data-driven recommendations for resolution. Support the development of new edits and clinical coding policies in response to industry or client needs. Contribute to training efforts and share insights for continuous improvement initiatives. Maintain high standards of documentation, audit readiness, and internal data accuracy. Required Qualifications: Minimum of 2 years’ experience in healthcare claims processing, payer operations, or clinical coding analysis. Certified coder credential required (CPC, CCS, or CCS-P). Ability to interpret claim edit rules, reference clinical coding standards, and perform in-depth root-cause analysis. Strong understanding of clinical policies, payer edits, medical necessity, and reimbursement guidelines. Proficiency with Microsoft Excel and data manipulation. Excellent verbal and written communication skills, with a collaborative team mindset. Experience reviewing medical records and applying NCCI and related guidelines. Familiarity with both professional and facility claim forms and standard billing practices. Preferred Qualifications: Licensed RN, LPN, or LVN (preferred but not required). Bachelor’s degree in Nursing, Health Information Management, or related field. Knowledge of provider-payer dynamics and experience managing business relationships. Experience working with health plans, TPAs, or payment integrity vendors. Job Types: Full-time, Permanent Pay: From ₹20,000.00 per month Work Location: In person
