We are seeking a highly motivated and clinically experienced Senior Clinical Coding Specialist to join our team of Clinical Informaticists (Analytics) , contributing to our efforts in transforming healthcare delivery through Value-Based Care (VBC) initiatives. The ideal candidate will have a deep understanding of the U.S. healthcare system, a strong clinical background, and a passion for leveraging data to drive better health outcomes and cost efficiencies.
This role bridges clinical knowledge with analytics, supporting strategic decision-making and operational excellence across value-based care programs.
- HCC coding
- VBC models
- suspect logic
- EMR, EHR
Clinical Strategy Support
- Provide clinical insights and subject matter expertise to support clients with the design, implementation, and optimization of value-based care models.
- Models include HCC coding, disease level coding, utilization patterns, chronic care management strategies, risk modelling.
- Provide insights from the Client data [clinical, payer claims and ADT] with Strategies that could be adopted and operationalized, to influence patient outcomes and revenue for the organization, with patients under the Fee-For-Service model.
- Collaborate with internal stakeholders (risk analysis, care management, quality improvement, IT, analytics) to develop care models and dashboards that inform on the organizations performance that are designed to improve patient outcomes and reduce total cost of care.
ValueSet Evaluation Maintenance
o Validate ValueSets for accuracy and alignment with payer criteria
o Identify missing or incorrect codes that impact clinical rules logic
Authoring Version Control
- Create and manage ValueSets
- Maintain audit logs and track updates to keep rules current
Clinical Coding Terminology Expertise
o Serve as the coding expert for SNOMED, LOINC, CPT, ICD-10-CM, RxNorm
o Translate clinical guidelines into accurate code sets
o Interact with Analytics and Customer Success teams to help develop and validate NLP tools for clinical coding and documentation
Collaboration with Product Engineering
o Prioritize rule development with product and clinical teams
o Ensure proper ValueSet binding and participate in QA reviews
Data Quality Model Support
o Review EHR data to confirm ValueSet effectiveness
o Identify and correct data mismatches or terminology gaps
Scalability Coverage Expansion
o Build reusable ValueSet templates for scalable rule creation
o Support expansion across CPTs, payers, and clinical domains
Data Analysis Interpretation
o Analyse clinical and payer claims data to identify trends, care gaps, and performance opportunities in VBC and non-VBC arrangements (e.g., ACOs, MSSP, MA, Medicaid Managed Care, Fee-For-Service).
o Use tools like SQL, Excel, or Power BI to extract and interpret data to inform clinical interventions and operational planning.
o Assist with the design and content of Dashboards that are built within PowerBI
Performance Monitoring Reporting
o Develop and review reports + design dashboards on clinical quality, Measurable
o Patient Outcomes including utilization, and cost metrics tied to Patient Care for any patient population.
o Help evaluate the effectiveness of care interventions and population health programs using data-driven insights.
Stakeholder Communication
o Present findings and recommendations to both clinical and non-clinical stakeholders, translating data into actionable strategies.
o Act as a liaison between clinical teams and data/IT teams to ensure data needs are well-communicated and accurately implemented as well as managing SME relationships with Customer Success Teams (client facing leaders of client
Management), finding the balance and enabling the team with the information and, becoming the trusted advisor with the clinical information.
Regulatory Contractual Awareness
o Maintain up-to-date knowledge of CMS, NCQA, HEDIS, and other regulatory frameworks relevant to VBC and other CMMI programs
o Understand payer requirements and assist with compliance and reporting for risk-bearing contracts
Qualifications and Experience
Clinical Experience
o 5+ years of clinical experience in a healthcare setting.
o Minimum two years of medical coding experience
o Any US healthcare experience would be an additional asset
o Strong understanding of the U.S. healthcare system, including value-based care models
Understanding medical terminologies (RxNorm, LOINC, SNOMED, CPT, ICD-10-CM, CPT, HCPCS, etc.)
Understanding of body systems/anatomy, physiology and concepts of disease processes.
Hands-on experience with value set authoring tools (e.g., FHIR terminology services) is preferable.
Knowledge of HL7 FHIR terminology resources and value set binding methodologies
Deep understanding of clinical workflows, EHRs, and clinical documentation guidelines for medical coding.
Experience using clinical data and analytics to help develop new solutions to existing healthcare problems. and population health strategies.
Intermediate understanding of SQL and experience working with clinical or claims datasets.
Familiarity with data visualization and reporting tools (e.g., Excel, Power BI, Tableau).
Ability to translate clinical and operational challenges into data requirements and actionable insights.
Proven ability to review and provide feedback on AI-generated coding outputs.
Stay updated on industry changes and attend relevant training sessions
Ability to work in US central time zone while in India typically 12 noon to 20 30 IST
Preferred
: - Experience working in the US healthcare environment plan, strong familiarity with ACO s, healthcare systems, or population health management setting.
- Knowledge of HCC coding, risk adjustment, and quality metrics (e.g., HEDIS, STAR ratings).
- Experience working with Python, R, or SAS for data manipulation and statistical analysis.
- Background in quality improvement, utilization management, or care coordination is preferred
Core Competencies
- Analytical thinking and clinical problem-solving
- Strong communication and presentation skills
- Cross-functional collaboration and team orientation
- Attention to detail with a systems-thinking mindset
- Passion for improving healthcare delivery and outcomes
