Senior Content Analyst (Claims editing)

What You’ll Do

Policy Interpretation & Edit Development

• Interpret and apply CMS, Medicare, Medicaid, AMA/CPT, NCCI, and other payer policies to define accurate claims editing logic.
• Translate regulatory and coding guidance into clear, deterministic pre-pay edits, with documented rationale and references.
• Build and maintain a proprietary library of claims edits aligned to reimbursement rules and industry standards.
• Identify reimbursement risk areas and policy interpretation gaps and encode them into actionable edit concepts.

Claims Validation & Analysis

• Own the development of high-quality edit specifications, including logic definitions, assumptions, edge cases, and validation criteria.
• Analyze claims and edit performance data to confirm accuracy, reduce false positives, and prioritize enhancements by impact.
• Conduct targeted manual claim reviews to validate coding accuracy, reimbursement correctness, and policy alignment.

Cross-Functional Enablement

• Serve as a SME across Medicare, Medicaid, and commercial claims.
• Partner with product, engineering, and implementation teams to ensure edits are implemented and validated correctly.
• Clearly document edit logic, policy interpretation, and outcomes to support internal teams and payer stakeholders.

Governance & Ongoing Maintenance

• Proactively monitor regulatory updates, coding changes, and industry guidance to keep edits current and compliant.
• Ensure all edits are auditable, defensible, and aligned with external policy sources.
• Consistently meet productivity and quality expectations in a remote, outcomes-driven environment.

What You Bring

• 4+ years of experience in authoring claims editing content with either vendors or payers
• Deep expertise in:
  • CMS policies (LCDs, NCDs, fee schedules)
  • NCCI (PTP and MUE) edits, OIG guidance, correct coding methodologies
  • CPT/HCPCS, ICD-10-CM/PCS, modifiers, place of service, and revenue codes
• Strong understanding of claims processing workflows (CMS-1500, UB-04).

Extra points if you bring:

• SQL skills for claims analysis or edit opportunity identification.
• Clinical background (RN, BSN, PharmD, MD, or equivalent).