Content Innovation, Claims Editing

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

📋 Description

• Oversee and analyze CPT, HCPCS, ICD-10-CM, NCCI, MUE, CMS, specialty society, payer, and New York Medicaid resources.

• Convert coding regulations, clinical protocols, and reimbursement policies into accurate, verifiable editing logic.

• Record sources, reasoning, and scope of edits for traceability and appeals documentation.

• Distinguish general market-wide content from client-specific policies.

• Update content in response to code alterations, policy modifications, and performance assessments.

• Develop New York Medicaid content for Mainstream Managed Care, HARP, behavioral health, FQHC, and long-term care services.

• Utilize claims data to validate concepts, identify opportunities, and estimate hit rates, false positives, and savings.

• Assess production outcomes and monitor accuracy, appeals, overturns, provider friction, and actual savings.

• Collaborate with Product, Engineering, and Data Science teams on requirements, logic specifications, testing scenarios, and AI-driven content workflows.

• Articulate content rationale and its implications to clients and internal teams; assist in policy reviews, approvals, and appeals.

• Within the first 90 days, familiarize yourself with the content portfolio and present a prioritized list of gaps and opportunities in New York content.

• Within 6–12 months, take ownership of a content domain, transition data-validated concepts into production, maintain documentation, enhance content creation processes, and demonstrate measurable outcomes.

⛳️ Requirements

• Over 7 years of experience in claims editing, clinical coding, Payment Integrity, or payer policy, with direct involvement in authoring or validating edits.

• Active coding certification, such as CPC, CCS, CCS-P, CPMA, or CIC, or a clinical license like RN combined with extensive coding experience.

• In-depth, up-to-date understanding of CPT, HCPCS, ICD-10-CM, modifiers, NCCI, MUEs, coding standards, and documentation necessities.

• Familiarity with reimbursement models, including fee schedules, DRGs, APCs, and both professional and facility billing.

• Experience sourcing and interpreting CMS manuals, NCDs and LCDs, AMA guidance, and payer regulations.

• Strong analytical capabilities and comfort with claims data analysis, utilizing SQL, Excel, or similar tools.

• Background in collaborating with Product, Engineering, Data Science, or other multidisciplinary teams.

• Proficient written communication skills with the ability to convey complex coding and clinical logic to nonclinical audiences.

• Interest in AI tools and an eagerness to incorporate them into daily content tasks.

• Minimum of 3 years’ experience with New York State Medicaid policy, billing, or Payment Integrity, including familiarity with eMedNY, APGs, APR-DRGs, and NYS DOH and OMIG guidelines.

• Sound judgment and ability to operate in a fast-paced build-and-scale environment.

🏝️ Benefits

• PTO, Paid Holidays, and Volunteer Days.

• Eligibility for health, vision, and dental coverage.

• Participation in a 401(k) plan with company match.

• Flexible spending accounts.

• Tuition Reimbursement.

• Company-paid life insurance.

• Company-paid short-term disability.

• Company-paid parental leave.

• Options for remote and hybrid work.