Clinical Content & Editing Reimbursement Manager
Core
Manages development and execution of clinical content and provider reimbursement strategies to ensure payment accuracy, regulatory compliance, and cost-of-care initiatives across Commercial, Medicare, and Medicaid lines.
Role type
Senior IC reimbursement manager (healthcare payer)
Builds
Clinical editing rules, reimbursement solutions, and payment integrity strategies
Domain
Healthcare payer / Insurance / Reimbursement
Deliverable
production ML models | product features | dashboards & analysis
Required skills
financial modeling, economic analysis, CMS regulations interpretation, CPT/HCPCS/ICD-10 coding, NCCI edits, Medicare/Medicaid policies, data analysis, SQL, Excel (PivotTables, VLOOKUP/XLOOKUP)
Preferred skills
claims editing, payment integrity, provider reimbursement, clinical content development, claims adjudication, billing, revenue cycle, automated claims editing logic, SAFe
Technologies
SQL, Microsoft Excel
Responsibilities
Lead development of clinical editing rules for payment integrity; perform complex fee modeling and reimbursement analyses; research and interpret CMS/NCCI/Medicaid policies; collaborate with Engineering/Product teams to translate policies into editing specifications; oversee validation of reimbursement methodologies and editing logic; manage strategic reimbursement initiatives.
Seniority
Senior, hands-on IC