Clinical Analyst – Outpatient Methodology Groupers

This is a fully remote position, open to applicants in Connecticut.

📋 Description

• Design, develop, and maintain Solventum's outpatient public and proprietary methodologies, code editors, and software such as Tricare, Home Health, IOCE, and EAPG.

• Conduct thorough validation and testing analysis of healthcare data to assess methodology performance and pinpoint anomalies and improvements.

• Act as a methodology expert and collaborate with the Research team on methodology-related initiatives.

• Contribute to the prioritization of potential methodology improvements.

• Work alongside the Chief Product Owner, Product Owners, and Development team to advance methodology enhancements.

• Convert clinical concepts into documented, executable logic content specifications utilizing ICD-10-CM, CPT, and HCPCS.

• Leverage knowledge of the healthcare revenue cycle as well as outpatient coding and billing practices.

• Partner with technical, quality, and clinical team members to create software components for each methodology.

• Maintain process documentation for methodologies and generate update summaries and descriptive documents in accordance with C&ER standards and methods.

• Adhere to corporate policies, procedures, and security protocols.

⛳️ Requirements

• Bachelor's degree or higher (completed and verified prior to start) from an accredited institution.

• Over 5 years of experience in the healthcare sector, particularly in outpatient medical coding and billing operations, outpatient prior authorization or denials management, outpatient healthcare claims processing optimization, payor claims design and edit management, or outpatient healthcare services research and analytics.

• Strong proficiency in HCPCS/CPT, ICD-10-CM, and standard claims processing.

• Expertise in ICD-10-PCS, APC, and DRG classification and reimbursement methodologies.

• Extensive experience with Excel and databases.

• Capability to learn computer applications for analytical purposes.

• Familiarity with AI applications for research, analytics, and process automation.

• Must possess legal authorization to work in the country of employment without sponsorship for employment visa status.

• High integrity and strong work ethic.

• Master's degree in a health-related field, clinical informatics, clinical coding, and/or HIM credentials is preferred.

• Knowledge of patient classification research and development, outpatient coding and payment systems, and commercial, Medicare, and Medicaid environments, as well as risk adjustment, Medicare claims processing, and data analysis.

• Experience in developing payment and quality measures.

• Ability to assess research questions, analyze results and statistical outputs and patterns, and document hypotheses and recommendations.

• Experience in healthcare software product development.

• Background in healthcare payer, delivery, or industry experience in healthcare quality, population health, or care management.

🏝️ Benefits

• Medical, Dental & Vision coverage.

• Health Savings Accounts.

• Flexible Spending Accounts for Health Care & Dependent Care.

• Disability Benefits.

• Life Insurance.

• Voluntary Benefits.

• Paid Absences.

• Retirement Benefits.

• Company-paid travel arrangements and related expenses for on-site onboarding.