Research Policy - Semi automated Claims Validation/Payment Integrity

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: To play a critical role within the CoverSelf Content team, contributing to the development, enhancement and maintenance of medical policy content. This position is responsible for researching new medical policies, ensuring quality assurance, and identifying opportunities to expand policy libraries. This role will also conduct in-depth reviews of existing medical policies and support the development of clinical logic and algorithms for Semi automated claims review.We are seeking a passionate and experienced Subject Matter Expert (SME) with strong hands-on expertise in one or more of the following areas:

• Claims prepayment review
• Payment Integrity
• Clinical Coding Analyst
• Content Development
• Payment Integrity Data mining
• Medical Coding
• Denials Management
• Clinical documentation improvement

Specialty Expertise:

• Candidates must have proficiency in coding and billing for one or more of the following specialties:
• Evaluation & Management (E/M) Services
• Surgery
• Anesthesia
• Radiology
• DME
• Any Medical Coding Specialty

Key Responsibilities:

• Identify, interpret, develop, and implement concepts to detect incorrect healthcare payments through semi automated claims validation
• Develop and maintain Semi automated claims review frameworks & Algorithms
• Manually review the claims, identify the incorrect coding /Billing and Flag those claims
• Analyst to support managing 1-2 medical reimbursement payment policies end-to-end.
• Manager and above to manage 2-3 medical reimbursement payment policies end-to-end.
• Analyze medical reimbursement methodologies, including policy rules and edits.
• Synthesize complex clinical and coding guidelines into actionable business logics
• Ensure compliance and update rules according to the latest industry standards.
• Leverage expertise in medical coding, healthcare claims processing, and industry standards to support the development of clinical coding policies and edits.
• Operate independently as an individual contributor

Requirements:

• Strong domain expertise Semi automated Claims review
• Solid understanding of medical coding & billing methodologies and guidelines, including CPT, ICD, LCD/NCD, PTP, NCCI, edits, modifiers, Medicare Physician fee schedule, and coding conventions.
• Proficiency in data collection, analysis, and deriving actionable insights from CMS medical policies, Medicaid Provider Manuals and other Medical publications.
• Translate industry references into actionable business logic to support new rules and policy enhancements.
• Strong understanding of claim forms like UB-04/CMS 1450 and CMS 1500
• Collaborate effectively across teams while managing multiple priorities
• Ability to thrive in a fast-paced, dynamic environment with minimal supervision.
• Demonstrated mindset for continuous learning and improvement and apply insights to policy development, refinement and maintenance.
• Strong stakeholder management, interpersonal, and leadership skills.
• Solution-focused, motivated, entrepreneurial spirit with a strong sense of ownership.
• Clear and effective communication.
• Strong attention to accuracy and detail in all deliverables

QualificationsEducation & Certification (one of the following required):

• Medical Degree (e.g., MBBS, BDS, BPT, BAMS etc)
• Nursing: Bachelor/Master of Science in Nursing
• Pharmacist Degree (B.Pharm, M.Pharm or PharmD)
• Life Science -Bachelor/Master

Certification Requirements:

• Must hold any of the following certifications: CPC, CPMA, COC, CIC, CPC-P, CCS or any specialty certifications from AHIMA or AAPC.
• Additional weightage will be given for AAPC specialty coding certifications.
• Lean Six Sigma certification and practical application experience are preferred.

Experience:

• Experience in Payment Integrity Content/Research, Semi automated Claims Review
• 3+ years experience for Analyst
• 5+ years experience for TL
• 10+ Years for Manager
• 13+ years for Senior Manager
• Experience in rule requirement Semi automated Claims Review.
• In-depth knowledge of Reimbursement payment policies, Medical coding Denial Management is required.

Key Skills:

• Nurse claims Review
• Coding Validation
• 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.
• Payment Policies knowledge like Medicare/Medicaid Reimbursement, Payer Payment Policies, NCCI, IOMs, CMS Policies etc
• High 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

Work Details:

• Location: Jayanagar, Bangalore
• 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!

Our Commitment to Diversity:At CoverSelf, we are building a global workplace where every individual can discover their true potential, passion, and purpose — regardless of background, gender, race, sexual orientation, religion, or ethnicity. We believe a diverse workplace fosters innovation, creativity, and progress for our employees, communities, and business.

Job Types: Full-time, Permanent

Pay: ₹20,000.00 - ₹50,000.00 per month

Benefits:

• Health insurance
• Provident Fund

Work Location: In person