Clinical Content Specialist (Payment Integrity)

Experience: 1-3

About CoverSelf: CoverSelf empowers US healthcare payers with a truly next-generation, cloud-native, holistic, and customizable platform designed to prevent and adapt to the ever-evolving inaccuracies in healthcare claims and payments. By reducing complexity and administrative costs, we offer a unified, healthcare-dedicated platform backed by top VCs like BeeNext, 3One4 Capital, and Z21 Ventures.

Position Overview: This role focuses on developing clinical content, payment integrity rules, and code edit solutions. The Clinical Content Specialist will translate clinical guidelines and payer policies into business logic, algorithms, and rule frameworks for automated claims validation.

Specialty Expertise: Payment Integrity Clinical Coding & Policy Development Claims Prepayment Review Data Mining & Content Development

Key Responsibilities: Develop and maintain payment integrity rules, edits, and policie Design clinical logic & algorithms for claims validation Translate CMS guidelines → business rules Build code edit solutions to detect incorrect payments Conduct research on medical policies and reimbursement methodologies Enhance and maintain policy libraries and rule frameworks Support semi-automated claims review systems

Requirements: Strong experience in Payment Integrity / Clinical Content / Policy building Ability to convert clinical guidelines into logical rules Knowledge of CMS policies, payer guidelines, and coding standards Strong analytical and problem-solving mindset

• Solid understanding of medical coding & billing methodologies and guidelines, including CPT, ICD, LCD/NCD, PTP, NCCI, edits, modifiers, Medicare Physician fee schedule, and coding conventions. • Proficiency in data collection, analysis, and deriving actionable insights from CMS medical policies, Medicaid Provider Manuals and other Medical publications. • Translate industry references into actionable business logic to support new rules and policy enhancements. • Strong understanding of claim forms like UB-04/CMS 1450 and CMS 1500 • Collaborate effectively across teams while managing multiple priorities • Ability to thrive in a fast-paced, dynamic environment with minimal supervision. • Demonstrated mindset for continuous learning and improvement and apply insights to policy development, refinement and maintenance. • Strong stakeholder management, interpersonal, and leadership skills. • Solution-focused, motivated, entrepreneurial spirit with a strong sense of ownership. • Clear and effective communication. • Strong attention to accuracy and detail in all deliverables Qualifications Education & Certification (one of the following required):

Experience:

• Best-in-class compensation • Health insurance for Family • Personal Accident Insurance • Friendly and Flexible Leave Policy • Certification and Course Reimbursement • Medical Coding CEUs and Membership Renewals • Health checkup • And many more! Our Commitment to Diversity: At CoverSelf, we are building a global workplace where every individual can discover their true potential, passion, and purpose — regardless of background, gender, race, sexual orientation, religion, or ethnicity. We believe a diverse workplace fosters innovation, creativity, and progress for our employees, communities, and business.