Clinical Analyst – Outpatient Methodology Groupers
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Job Description
Clinical analyst developing outpatient payment and quality methodologies for Solventum’s healthcare systems. Translating coding concepts into executable specifications and validating healthcare data.
Responsibilities:
- Design, develop, and maintain Solventum outpatient public and proprietary methodologies, code editors, and software including Tricare, Home Health, IOCE, and EAPG
- Perform in-depth validation and testing analysis of healthcare data to evaluate methodology behavior and identify anomalies and enhancements
- Serve as a methodology expert and coordinate with Research team efforts related to methodologies
- Provide input into prioritization of potential methodology enhancements
- Work with the Chief Product Owner, Product Owners, and Development team to drive methodology enhancements
- Translate clinical concepts into documented, executable logic content specifications using ICD-10-CM, CPT, and HCPCS
- Apply knowledge of healthcare revenue cycle and outpatient coding and billing
- Collaborate with technical, quality, and clinical team members to develop software components for each methodology
- Maintain methodology process documentation and produce update summaries and descriptive documents using C&ER standards and methods
- Comply with corporate policies, procedures, and security standards
Requirements:
- Bachelor or higher (completed and verified prior to start) from an accredited institution
- 5+ years’ experience in the healthcare industry in outpatient medical coding and billing operations, outpatient prior authorization or denials management, outpatient healthcare claims and processing optimization, payor claims design and edit management, or outpatient healthcare services research and analytics
- Strong expertise in HCPCS/CPT, ICD-10-CM, and standard claims processing
- Proficiency in ICD-10-PCS, APC, and DRG classification and reimbursement methodologies
- Significant experience working with Excel and databases
- Ability to learn computer applications for analysis
- Familiarity with use of AI for research, analytics and automation of processes
- Must be legally authorized to work in country of employment without sponsorship for employment visa status
- High integrity and work ethic
- Master's degree in a health field, clinical informatics, clinical coding, and/or HIM credentials preferred
- Familiarity with patient classification research and development, outpatient coding and payment systems, commercial, Medicare and Medicaid environments, risk adjustment, Medicare claims processing and data analysis
- Experience building payment and quality measures
- Ability to evaluate research questions, analyze results and statistical output and patterns, and document hypotheses and recommendations
- Healthcare software product development experience
- Healthcare payer, delivery or industry experience in healthcare quality, population health, or care management
Benefits:
- Medical, Dental & Vision
- Health Savings Accounts
- Health Care & Dependent Care Flexible Spending Accounts
- Disability Benefits
- Life Insurance
- Voluntary Benefits
- Paid Absences
- Retirement Benefits
- Company-paid travel arrangements and related expenses for on-site onboarding
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