Clinical Policy Specialist- Remote in US

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.

The Clinical Policy Specialist is responsible for the development and performance of our clinical solutions. This role requires expertise in healthcare payment methodologies, clinical policy interpretation, and audit criteria to target key claims for review and recovery. Proven experience in rule and content creation, claims data analysis, claims recovery, and coding expertise is essential. Key responsibilities include clinical policy research, regulatory monitoring, developing new content, analyzing data to support concept development, tracking performance, providing implementation and client support, conducting research, and reviewing claims data as needed. This role requires an expert in clinical areas including payment integrity, with the ability to lead the development of new solutions to drive the success of our clinical solutions and ensure optimal performance.

Content Development: Work in conjunction with the Medical Directors and Innovation Teams to develop new clinical and coding products. Develop innovative strategies to enhance audit strategy, claim selection processes, and significantly contribute to payment integrity for our clients. Data Analysis and Organization: Leverage data analysis expertise and strong organizational skills to innovate new ideas and solutions, including the development of Itemized Bill Review. Perform research and conduct scoping analysis for the development of coding, clinical targets, and edits. Claim Selection Methodology: Utilize 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 track performance. Present results to the 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 multi-disciplinary teams of data analytics leaders, operations leads, product leaders, and auditors to bring clinical and coding concepts from creation to implementation. Regulatory Monitoring: Assess and adjust policies and rules by monitoring their effectiveness, keeping up with regulatory updates, and making necessary changes. Monitor and research changes in clinical/coding guidelines and regulations and determine their impact on Gainwell programs. Policy and Process Documentation: Develop departmental policies, processes, and training standards. Provide internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances. Research and Special Projects: Assist with research, special projects, and ad hoc claim reviews as needed. Clinical and Coding Content: Develop clinical and coding content that will drive decision-making and documentation for the Clinical Services, Quality, and Appeals teams. Develop training and education, and work with clinical teams to ensure that coding content standards are well understood by all levels of the organization. SME Support: Maintain expertise in current Gainwell clinical and coding program processes, workflows, and results. Provide primary SME support regarding clinical policy, clinical, and coding review programs and processes to account management, sales, clients, and clinical teams. Client and Sales Support: Provide RFP SME Support. Meet with clients to explain programs and processes, discuss policy concerns, identify issues, and develop proactive solutions to problems that clients may be having or anticipate having with Gainwell clinical and coding review programs.