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Senior niche payer-coding role with specialized CMS/NCCI expertise, despite Optum brand, limits applicant competition.
Highly healthcare-specific payer coding and CMS policy expertise limits transferability across industries.
Mandatory 8+ years of payer payment integrity, coding expertise, and clinical SME experience enforces strict shortlisting.
Lead clinical evaluation and in-depth review of US healthcare claims to detect fraud, waste, and abuse using coding and reimbursement policy expertise.
Drive clinical validation strategies and translate complex CMS, NCCI, and payer policies into actionable payment integrity insights with measurable impact on rule accuracy and provider relations.
Mentor junior analysts and collaborate with analytics teams to ensure clinical accuracy in data models and support strategic enhancements in payment integrity programs.
Undergraduate degree or equivalent experience.
Minimum 8 years of experience in US healthcare payment integrity, coding, or clinical claims review.
Expert-level knowledge of CPT, HCPCS, ICD-10-CM, DRG, modifiers, and complex billing practices.
Extensive experience interpreting CMS manuals, NCCI policies, LCD/NCD, and payer guidelines in specialties such as surgery, inpatient DRG, and E/M.
Experienced in leading or significantly contributing to payment integrity or large-scale fraud, waste, and abuse programs in the US healthcare payer domain.
Demonstrates advanced clinical subject matter expertise with capacity to develop clinical strategies and rules impacting payment integrity at scale.
Effective communicator comfortable with leadership/stakeholder engagement and mentoring analytic teams within complex healthcare environments.