Position Title
Clinical Analyst / Senior Clinical Analyst US Healthcare (Payment Integrity & Policy)
Locatio
nHyderabad / Bengaluru / Chenna
i Mode: Hybrid / Onsit
e Shift: US hours (as applicable
)
Position Overvi
ewThe Clinical Analyst / Senior Clinical Analyst will play a key role within the Research and Content function contributing to medical policy research, payment integrity initiatives, claims adjudication support, and quality assurance activitie
s.This role involves close collaboration with Operations, Product, QA, and Technology teams to ensure accurate, compliant, and efficient healthcare outcomes. The ideal candidate brings a strong clinical background, hands-on exposure to US healthcare payer operations, and a keen interest in policy-driven analytics and automatio
n.
Key Responsibilit
iesMedical Policy Research & Developm
- entResearch, interpret, and document Medicare and Medicaid policies (state and feder
- al)Create, review, and maintain payment integrity / IPU medical polic
- iesAlign policies with CMS guidelines and payer-specific requireme
- ntsPerform conflict reviews and periodic policy aud
its
Claims & Adjudication Sup
- portSupport medical claim adjudication for high-dollar and low-dollar cl
- aimsApply knowledge of ICD-10-CM, CPT, HCPCS, and NDC c
- odesReview claims for medical necessity, bundling, units, age/gender edits, and reimbursement accu
- racySupport initiatives to reduce denials and improve claims accu
racy
Quality Assurance & Compl
- ianceConduct quality assurance on policy rules and configurations with high accuracy stan
- dardsPerform UAT / BRAT testing and validate system
- logicIdentify issues, conduct root cause analysis, and support resol
- utionEnsure compliance with HIPAA, CMS, and state Medicaid regula
tions
Process Improvement & Auto
- mationSupport process improvement and shift-left initi
- ativesCollaborate with Product and Technology teams on automation opportu
- nitiesParticipate in workflow optimization to improve SLA and turnaround
times
Stakeholder Collaboration & Docume
- ntationAct as a point of contact for internal teams and client
- queriesParticipate in knowledge-sharing and training s
- essionsDocument policies, processes, and operational gui
delines
Qualif
icationsE
- ducationBachelor's degree in one of the fo
- llowing:Dent
- al (BDS)Medicine / Physiotherapy / Nursing / Allie
- d HealthMedical coding certification (CPC) is an added a
dvantage
E
- xperience28 years of experience in US healthcare operations, analytics, or payment
- integrityHands-on experience in one or more of the f
- ollowing:Medicaid / Medicare
- researchMedical policy creation, maintenan
- ce, or QAClaims adjudication or healthcare
analytics
Requi
red SkillsDomain & Functio
- nal SkillsStrong understanding of the US healthcare payer
- ecosystemKnowledge of Medicaid and Medicare reimbursemen
- t policiesExposure to payment integrity and IPU rule
- frameworksMedical coding knowledge (ICD-10, C
- PT, HCPCS)Policy audits and compliance
management
