Evaluation & Management Professional

We are seeking a passionate and experienced Subject Matter Expert (SME) with strong hands-on expertise in one or more of the following areas:

• Payment Integrity.
• Clinical Coding Analyst.
• Content Development.
• Payment Integrity Data Mining.
• Medical Coding.
• Denials Management.

Specialty Expertise: Candidates must have proficiency in coding and billing for one or more of the following specialties:

• Evaluation & Management (E/M) Services.
• E/M Professional (IP/OP).
• Observations.
• Emergency Medicine Professionals.

Key Responsibilities:

• Identify interpret develop and implement concepts to detect incorrect healthcare payments through regulatory research industry expertise and data analysis.
• 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.
• Develop and maintain coding guidelines Medicare/Medicaid edits and reimbursement frameworks.
• 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 in denials logic across Payment Integrity Revenue Integrity and Denials Management.
• 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.

Qualifications: Education & Certification (one of the following required):

• Medical Degree (e.g. MBBS BDS BPT BAMS etc).
• Bachelor of Science in Nursing.
• Pharmacist Degree ( or PharmD).
• Life science Degree (Microbiology Biochemistry etc).
• Other Bachelors Degree with relevant experience.

Certification Requirements:

• Must hold any of the following certifications: CPC CEMC CEDC 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 Denial Management or Medical Coding.
• 3 years experience for Analyst.
• 5 years experience for TL.
• 10 Years for Manager.
• 13 years for Senior Manager.
• Experience in rule requirement gathering rule development and maintenance and Resolving payer denials.
• In-depth knowledge of Reimbursement payment policies Medical coding Denial Management is required.

Key Skills:

• Domain Expertise in US Healthcare Medical Coding Medical Billing Payment IntegrityRevenue 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!