Senior Content Analyst (Claims editing)

As a Sr. Content Analyst on the Payment Integrity – Policy & Content Management team, you will interpret healthcare reimbursement policies and translate them into precise, automated claims editing logic that drives payment accuracy. This is a deep subject-matter-expert role focused on applying regulatory guidance, coding standards, and payer rules to create deterministic, testable edits that identify incorrect coding, billing, and reimbursement. You’ll own edit concepts end-to-end, from interpretation through validation and ongoing refinement, with opportunities to contribute to the evolution of content approaches over time. This role offers high autonomy and ownership for someone who understands how claims should be paid and thrives on turning complex rules into clear, enforceable logic.

Policy Interpretation & Edit Development

• Interpret and apply CMS, Medicare, Medicaid, AMA/CPT, NCCI, and other payer policies to define accurate claims editing logic.
• Translate regulatory and coding guidance into clear, deterministic pre-pay edits, with documented rationale and references.
• Build and maintain a proprietary library of claims edits aligned to reimbursement rules and industry standards.
• Identify reimbursement risk areas and policy interpretation gaps and encode them into actionable edit concepts.

Claims Validation & Analysis

• Own the development of high-quality edit specifications, including logic definitions, assumptions, edge cases, and validation criteria.
• Analyze claims and edit performance data to confirm accuracy, reduce false positives, and prioritize enhancements by impact.
• Conduct targeted manual claim reviews to validate coding accuracy, reimbursement correctness, and policy alignment.

Cross-Functional Enablement

• Serve as a SME across Medicare, Medicaid, and commercial claims.
• Partner with product, engineering, and implementation teams to ensure edits are implemented and validated correctly.
• Clearly document edit logic, policy interpretation, and outcomes to support internal teams and payer stakeholders.

Governance & Ongoing Maintenance

• Proactively monitor regulatory updates, coding changes, and industry guidance to keep edits current and compliant.
• Ensure all edits are auditable, defensible, and aligned with external policy sources.
• Consistently meet productivity and quality expectations in a remote, outcomes-driven environment.