Job
Description
About CoverSelf: CoverSelf empowers US healthcare payers with a truly next-generation, cloud-native, holistic, and customizable platform designed to prevent and adapt to the ever-evolving inaccuracies in healthcare claims and payments. By reducing complexity and administrative costs, we offer a unified, healthcare-dedicated platform backed by top VCs like BeeNext, 3One4 Capital, and Saison Capital. Position Overview: This position plays a vital role within the CoverSelf Payment Integrity team by contributing to the development, enhancement, and maintenance of medical policy content. The role is responsible for converting healthcare guideline-driven concepts into system-readable configurations and performing comprehensive testing to ensure accuracy. Responsibilities include configuration and testing, ensuring adherence to CoverSelf and industry standards, and collaborating with cross-functional teams to validate outputs and maintain quality. This role needs passionate people with good interpersonal, analytical & problem solving skills. Having hands-on expertise in one or more of the following areas is an added advantage. Payment Integrity. Clinical Coding. Medical Coding. Denials Management. Key Responsibilities: Analyze and interpret concepts to ensure accurate configuration in line with medical coding, billing, and reimbursement guidelines. Analyze medical coding, reimbursement guidelines and configure logic to support accurate concept execution. Conduct in-depth reviews of contracts, policies, and federal/state regulations to formulate edit requirements. Apply industry coding guidelines to claims processes effectively. Demonstrate experience in analyzing and resolving coding issues for payment integrity purposes. Analyze, develop, and implement system configurations. Collaborate with subject matter experts (SMEs) and technical teams to translate regulatory and policy requirements into functional edit specifications. Translate editing logic into platform configurations with support from SMEs, and stakeholders to ensure clear understanding and configuration of concepts. Collaborate with cross-functional teams to assess configuration needs and implement appropriate solutions. Assist in developing and maintaining payment integrity policies and procedures. Review configurations to ensure completeness and accuracy based on the medical coding and billing guidelines. Troubleshoot and perform root-cause analysis for edit logics not functioning as intended. Effectively pinpoint configuration discrepancies and ensure concepts are deployed successfully and on schedule. Audit and validate concepts against healthcare guidelines; identify and address gaps with upstream teams. Conduct rigorous testing to verify concept accuracy and performance across outpatient, professional, and inpatient claim scenarios adhering to the coding guidelines. Perform acceptance testing to validate configuration accuracy. Stay updated with industry regulations and compliance requirements to ensure the configuration process adheres to relevant standards. Perform duties independently with a high level of accuracy and professionalism. Exhibit detail-oriented mindset with a focus on quality and accuracy in concept configuration & testing. Key Skills: Domain Expertise in US Healthcare Medical Coding, Medical Billing, Payment Integrity, Revenue Cycle Management (RCM), Denials Management. Codeset Knowledge like CPT/HCPCS, ICD, Modifier, DRG, PCS, etc. Knowledge on policies like Medicare/Medicaid Reimbursement, Payer Payment Policies, NCCI, IOMs, CMS Policies etc. Proficiency in Microsoft Word and Excel, with adaptability to new platforms. Excellent verbal & written communication skills. Excellent Interpretation and articulation skills. Strong analytical, critical thinking, and problem-solving skills. Willingness to learn new products and tools. Strong time management skills and ability to meet deadlines. Qualifications: Education & Certification (one of the following required): Bachelor of Science in Nursing (B.Sc. Nursing). Pharmacist Degree (B.Pharm, M.Pharm or PharmD). Life science Degree (Microbiology, Biotechnology, Biochemistry, etc). Medical Degree (e.g., MBBS, BDS, BPT, BAMS etc). Other Bachelor s Degree with relevant experience. Certification Requirements: Candidates with certifications like CPC, CPMA, COC, CIC, CPC-P, CCS, or any specialty certifications from AHIMA or AAPC will be given preference. Additional weightage will be given for AAPC specialty coding certifications. Experience: 0-1 years of experience in Payment Integrity, Medical Coding, Denial Management. Experience in payment integrity, claims processing, or related functions within the US healthcare system. Experience in denial management, retrospective payment audits, or medical coding. Familiarity with Medical coding guidelines, such as ICD, CPT, Modifiers, Medicare, Medicaid, or commercial payer guidelines. Work Location: Jayanagar - Bangalore. Work Mode: Work from Office. Benefits: Best-in-class compensation. Health insurance for Family. Personal Accident Insurance. Friendly and Flexible Leave Policy. Certification and Course Reimbursement. Medical Coding CEUs and Membership Renewals. Health checkup. And many more! Additional Information: At CoverSelf, we are creating a global workplace that enables everyone to find their true potential, purpose, and passion irrespective of their background, gender, race, sexual orientation, religion and ethnicity. We are committed to providing equal opportunity for all and believe that diversity in the workplace creates a more vibrant, richer work environment that advances the goals of our employees, communities and the business.
