Clinical Content Specialist (Payment Integrity)

About CoverSelf:CoverSelf empowers US healthcare payers with a truly next-generation, cloud-native, holistic, and customizable platform designed to prevent and adapt to the ever-evolving inaccuracies in healthcare claims and payments. By reducing complexity and administrative costs, we offer a unified, healthcare-dedicated platform backed by top VCs like BeeNext, 3One4 Capital, and Z21 Ventures.

Position Overview:This role focuses on developing clinical content, payment integrity rules, and code edit solutions. The Clinical Content Specialist will translate clinical guidelines and payer policies into business logic, algorithms, and rule frameworks for automated claims validation.

Key Responsibilities:Develop and maintain payment integrity rules, edits, and policies Design clinical logic & algorithms for claims validationTranslate CMS guidelines → business rulesBuild code edit solutions to detect incorrect paymentsConduct research on medical policies and reimbursement methodologiesEnhance and maintain policy libraries and rule frameworksSupport semi-automated claims review systems

• Strong experience in Payment Integrity / Clinical Content / Policy building
• Ability to convert clinical guidelines into logical rules
• Knowledge of CMS policies, payer guidelines, and coding standards
• 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
• Must hold any of the following certifications: CPC, 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.