Clinical Content Analyst

Elevance Health - Durham, NC

Full-time - Mid Level

Durham, NC

Insurance Carriers and Related Activities

About the position

The Clinical Content Analyst will be responsible for driving the development and execution of the clinical content scope in alignment with the product and content strategy to meet financial and operational targets. The role will research and interpret CMS, CPT/AMA and other major payer policies based on healthcare correct coding and regulatory requirements.

Responsibilities

• Oversees the conception and development of new content.
• Takes edits from concept to specification and then through review, testing and finally data validation.
• Develops claims editing logic and content that promotes payment accuracy and transparency across Medicaid, Medicare, and Commercial lines of business.
• Identifies common error areas that can be made into automated software logic that prevent overpayments from occurring.
• Provides data-based reports and recommendations to optimize content performance and guide content strategy.
• Reviews healthcare policy for coding and billing guidelines that can be turned into software editing rules.
• Creates billing edits that provide clients with monetary savings and promote coding accuracy.
• Uses structural design to turn policy language into specifications that developers turn into software coding edits or logic.
• Builds unit tests to verify the functionality of the edits.
• Applies revenue cycle, coding, and billing expertise to interpret policy based on correct coding, billing, and auditing guidelines.
• Provides in-depth research on regulations and supports edits with official documents.
• Validates if edits are working as intended and supports decisions with validation data.
• Presents to business partners (internal/external) to demonstrate the content value.
• Maintains current industry knowledge of claim edit references.
• Collaborates with the Content and Engineering and Data teams to develop, adjust, and validate edits.
• Meets weekly productivity and quality goals.
• Curates source content.
• Develops and maintains the content plan, owns and manages content maintenance plan to ensure content supports strategy.
• Contributes to a core center of excellence for digital editing content.
• Serves as a lead role and has dotted line resource accountability.
• Directs and supervises the conception and development of new content.

Requirements

• Requires a BA/BS in a related field and a minimum of 5 years of related experience; or any combination of education and experience, which would provide an equivalent background.

Nice-to-haves

• Master's Degree strongly preferred.
• Scaled Agile Framework Training strongly preferred.
• 5+ years of claims editing experience with healthcare payers and/or claims editing software vendors, strongly preferred.
• Billing, coding, revenue cycle, and claims editing software experience strongly preferred.
• Nationally recognized coding or billing credential required: CCS, CCS-P, CPC, CPB strongly preferred.
• Experience in claims adjudication and application of NCCI editing and claims payment rules strongly preferred.
• Ability to interpret claim edit rules and references strongly preferred.
• Solid understanding of claims workflow including the interconnection with claim forms strongly preferred.
• Ability to apply industry coding guidelines to claim processes strongly preferred.
• Proven experience reviewing, analyzing, and researching coding issues for payment integrity strongly preferred.
• Ability to break policy edits down into decision making paths preferred.
• Ability to troubleshoot and apply root-cause analysis of logics not functioning as intended preferred.
• Intermediate level proficiency in Excel preferred.
• SQL query-building and lookup skills preferred.

Benefits

• Merit increases
• Paid holidays
• Paid Time Off
• Incentive bonus programs
• Medical benefits
• Dental benefits
• Vision benefits
• Short and long term disability benefits
• 401(k) + match
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources