Clinical Content Lead

2 days ago

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Apixio

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Advancing Healthcare Operations and Delivery with an AI Platform

Healthcare Provider Solutions • Payer Solutions • Risk Adjustment Technology • Health Plans Solutions • Prospective Solutions

201 - 500

Description

• The Clinical Content Lead is responsible for the development and management of our clinical solutions, including Readmissions, Place of Service, Level of Care, and APR-DRG validation clinical concepts. • This role requires expertise in healthcare payment methodologies and audit and review criteria to target key claims for review and recovery. • Proven experience in rule and content creation, claims recovery, and APR-DRG expertise is essential. • Key responsibilities include developing content, tracking performance, providing implementation and client support, conducting research, and reviewing claims as needed for proof of concepts. • This role requires an expert in clinical areas in addition to payment integrity, with keen attention to detail and analytical skills to drive the success of our clinical solutions and ensure optimal performance.

Requirements

• Bachelor’s degree (health administration, business, nursing) • Equivalent experience of 5+ years in healthcare billing and coding • Equivalent experience of 3+ years in claims auditing and recovery auditing • Extensive experience in APR-DRG methodology for clinical content development • Proven experience working within a team, sharing DRG audit process knowledge with sales, marketing, and development teams • Proven knowledge of classification systems, including MSDRG, APR DRG, AP DRG, and outpatient payment systems such as APCs and EAPGs • Demonstrated curiosity and mastery in understanding the root cause of events and behaviors • Strong experience in data utilization and insights • Experience independently structuring and executing complex analyses • Familiarity with Milliman and InterQual guidelines • Expertise in DRG validation • Experience in production and team management • Experience with Readmission reviews • Ability to work efficiently and effectively with minimal supervision • High standards of quality and attention to detail • Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems • Superior knowledge of healthcare coding, billing, reimbursement, and claim adjudication standards and procedures • Expert knowledge of clinical criteria documentation requirements • Subject matter expertise in APR-DRG validation, Readmissions, and Place of Service

Benefits

• Meaningful work to advance healthcare • Competitive compensation • Exceptional benefits, including medical, dental and vision, FSA • 401k with company matching up to 4% • Generous vacation policy • Remote-first & hybrid work philosophies • A hybrid work schedule (2 days in office & 3 days work from home) • Modern open office in beautiful San Mateo, CA; Los Angeles, CA; San Diego, CA; Austin, TX and Dallas, TX • Subsidized gym membership • Catered, free lunches • Parties, picnics, and wine-downs • Free parking