Job Description

Mode: Hybrid / Onsite
Shift: US hours (as applicable)
Key Responsibilities
Medical Policy Research & Development

• Research, interpret, and document Medicare and Medicaid policies (state and federal)
• Create, review, and maintain payment integrity / IPU medical policies
• Align policies with CMS guidelines and payer-specific requirements
• Perform conflict reviews and periodic policy audits

Claims & Adjudication Support

• Support medical claim adjudication for high-dollar and low-dollar claims
• Apply knowledge of ICD-10-CM, CPT, HCPCS, and NDC codes
• Review claims for medical necessity, bundling, units, age/gender edits, and reimbursement accuracy
• Support initiatives to reduce denials and improve claims accuracy

Quality Assurance & Compliance

• Conduct quality assurance on policy rules and configurations with high accuracy standards
• Perform UAT / BRAT testing and validate system logic
• Identify issues, conduct root cause analysis, and support resolution
• Ensure compliance with HIPAA, CMS, and state Medicaid regulations

Process Improvement & Automation

• Support process improvement and shift-left initiatives
• Collaborate with Product and Technology teams on automation opportunities
• Participate in workflow optimization to improve SLA and turnaround times

Stakeholder Collaboration & Documentation

• Act as a point of contact for internal teams and client queries
• Participate in knowledge-sharing and training sessions
• Document policies, processes, and operational guidelines

Qualifications
Education

• Bachelor's degree in one of the following:

• Dental (BDS)
• Medicine / Physiotherapy / Nursing / Allied Health
• Medical coding certification (CPC) is an added advantage

Experience

• 2-8 years of experience in US healthcare operations, analytics, or payment integrity
• Hands-on experience in one or more of the following:

• Medicaid / Medicare research
• Medical policy creation, maintenance, or QA
• Claims adjudication or healthcare analytics

Required Skills
Domain & Functional Skills

• Strong understanding of the US healthcare payer ecosystem
• Knowledge of Medicaid and Medicare reimbursement policies
• Exposure to payment integrity and IPU rule frameworks
• Medical coding knowledge (ICD-10, CPT, HCPCS)
• Policy audits and compliance management

Tools & Technology

• Advanced proficiency in Microsoft Excel (Pivot Tables, VLOOKUP, INDEX)
• Experience with Jira or similar workflow tools
• SQL and Tableau exposure is a plus
• Familiarity with EHR or claims processing systems preferred

Skills Required