Clinical Policy Specialist

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

Summary

The Nurse Coder - Product Specialist is responsible for the development and performance of our clinical and coding products including Itemized Bill Review, DRG Validation, Outpatient clinical and coding Solutions. This role also provides SME support to the clinical organization and clinical innovation team. This role requires expertise in healthcare payment methodologies and audit and review criteria to target key claims for review and recovery. Proven experience in rule and content development, claims recovery, and coding expertise is essential. Experience in developing and performing Itemized Bill Review concepts (IBR) is preferred. Key responsibilities include developing content, tracking performance, providing implementation and client support, conducting research, and reviewing claims as needed. Here are the details on this position.

Your role in our mission

• Content Development: Work in conjunction with the Medical Directors and Innovation Teams to develop new clinical and coding products. Develop innovative strategies to enhance claim selection processes, significantly contributing to payment integrity for our clients.
• Data Analysis and Organization: Leverages data analysis expertise and strong organizational skills to innovate new ideas and new concepts including development of Itemized Bill Review. Performing research and scoping analysis for development of coding and clinical target and edits. 
• Claim Selection Methodology: Utilizes a comprehensive understanding of claim selection methods to refine and execute methodologies that enhance claim selection strategies, particularly focused on inpatient claims.
• Program Performance: Monitor and analyze current and new concepts and target performance. Present results to clinical leadership team. Recommend and implement program changes to improve performance.
• Enhance Clinical and Coding Solutions: Utilize expertise to assist in the enhancement and review of clinical and coding solutions.
• Product Readiness: Work with a multi-disciplinary team of leadership to bring Clinic and Coding concepts from creation to implementation.
• Regulatory Monitoring: Assess and adjust written rules by monitoring their effectiveness, keeping up …