Nurse/Coder Ideation Specialist- Remote

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 Nurse/Coder Ideation Specialist is responsible for the development and performance of our clinical and coding products including Itemized Bill Review, DRG Validation, Outpatient clinical and other Coding Solutions. This role also provides SME support to the clinical and coding organization. This role requires expertise in healthcare payment methodologies, inpatient coding, outpatient coding, payment integrity audits 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.

Content Development: Work in conjunction with the Medical Directors and Innovation Teams to develop new clinical and coding products. The product focus is identifying overpayments made to provider by insurance companies through data review, data analytics, and application of coding guidelines. 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, outpatient claim reviews, other inpatient coding solutions. 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. Research: Research industry standard guidelines, State/Federal regulations, and client billing and reimbursement policies, to develop and configure improper payment algorithms Regulatory Monitoring: Assess and adjust written rules by monitoring their effectiveness, keeping up with regulatory updates, and making necessary changes. Monitor and research changes in coding guidelines and regulations and determines impact to Gainwell programs. Analytical Problem-Solving: Performs detailed analysis of client data to identify areas of high risk and drives concept development in those areas. 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 make sure 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 outcomes. 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.