Content Innovation, Claims Editing – Specialty Pharmacy

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, FDA, drug compendia, NCCN, pricing, and payer policy resources.

• Convert coding regulations, clinical guidelines, and reimbursement policies into accurate, testable editing logic.

• Record edit sources, rationales, and scopes for traceability and appeal purposes.

• Keep content updated through code revisions, policy alterations, and performance assessments.

• Develop and uphold specialty drug edits for billing units, NDC-to-HCPCS crosswalks, dosing, maximum units, dose rounding, and JW/JZ modifiers.

• Address oncology, immunology, rare diseases, biosimilars, and other high-cost therapeutic fields.

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

• Analyze production outcomes to pinpoint gaps, overreach, and overlooked opportunities.

• Collaborate with Product, Engineering, and Data Science teams on requirements, logic specifications, test cases, and clinical context.

• Assess AI tools and apply expert judgment to AI-generated materials.

• Assist in client policy reviews, edit approvals, appeals, and enhancements to the content roadmap.

• Take ownership of a content domain and transition data-validated concepts into production.

⛳️ Requirements

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

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

• Extensive, up-to-date knowledge of CPT, HCPCS, ICD-10-CM, modifiers, NCCI, MUEs, coding guidelines, and documentation standards.

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

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

• Strong analytical abilities and comfort in working with claims data using SQL, Excel, or similar tools.

• Experience 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 a willingness to incorporate them into daily content tasks.

• Minimum of 3 years of practical experience with medical benefit drug billing, coding, or policy, including HCPCS J-codes, NDCs, billing units, drug-related modifiers, and ASP-based reimbursement.

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

🏝️ Benefits

• PTO, Paid Holidays, and Volunteer Days.

• Eligibility for health, vision, and dental insurance.

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

• Flexible spending accounts.

• Tuition Reimbursement.

• Company-paid life insurance.

• Company-paid short-term disability.

• Company-paid parental leave.

• Remote and hybrid work options.