Senior Clinical Analyst - US Healthcare (Payment Integrity & Policy)

Location: Hyderabad / Bengaluru / Chennai

Mode: Hybrid / Onsite

Shift: US hours (as applicable)

Position Overview:

- 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 activities.

- 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 automation.

Key Responsibilities:

Medical Policy Research & Development:

- Research, interpret, and document Medicare and Medicaid policies (state and federal)

- Create, review, and maintain payment integrity / IPU medical policies

- Align policies with CMS guidelines and payer-specific requirements

- Perform conflict reviews and periodic policy audits

Claims & Adjudication Support:

- Support medical claim adjudication for high-dollar and low-dollar claims

- Apply knowledge of ICD-10-CM, CPT, HCPCS, and NDC codes

- Review claims for medical necessity, bundling, units, age/gender edits, and reimbursement accuracy

- Support initiatives to reduce denials and improve claims accuracy

Quality Assurance & Compliance:

- Conduct quality assurance on policy rules and configurations with high accuracy standards

- Perform UAT / BRAT testing and validate system logic

- Identify issues, conduct root cause analysis, and support resolution

- Ensure compliance with HIPAA, CMS, and state Medicaid regulations

Process Improvement & Automation:

- Support process improvement and shift-left initiatives

- Collaborate with Product and Technology teams on automation opportunities

- Participate in workflow optimization to improve SLA and turnaround times

- Stakeholder Collaboration & Documentation

- Act as a point of contact for internal teams and client queries

- Participate in knowledge-sharing and training sessions

- Document policies, processes, and operational guidelines

Qualifications:

Education:

Bachelor's degree in one of the following:

- Dental (BDS)

- Medicine / Physiotherapy / Nursing / Allied Health

- Medical coding certification (CPC) is an added advantage

Experience:

2-8 years of experience in US healthcare operations, analytics, or payment integrity

Hands-on experience in one or more of the following:

- Medicaid / Medicare research

- Medical policy creation, maintenance, or QA

- Claims adjudication or healthcare analytics

Required Skills:

Domain & Functional Skills:

- Strong understanding of the US healthcare payer ecosystem

- Knowledge of Medicaid and Medicare reimbursement policies

- Exposure to payment integrity and IPU rule frameworks

- Medical coding knowledge (ICD-10, CPT, HCPCS)

- Policy audits and compliance management

Tools & Technology:

- Advanced proficiency in Microsoft Excel (Pivot Tables, VLOOKUP, INDEX)

- Experience with Jira or similar workflow tools

- SQL and Tableau exposure is a plus

- Familiarity with EHR or claims processing systems preferred

Behavioral Competencies:

- Strong attention to detail and accuracy

- Excellent analytical and research skills

- Clear verbal and written communication

- Ownership mindset with adaptability to change

- Ability to thrive in a fast-paced US healthcare environment

What We Offer:

- Opportunity to work on impactful US healthcare initiatives

- Strong learning and growth opportunities in policy, product, and automation

- Collaborative and growth-oriented work culture

- Clear career progression path (Analyst - Senior Analyst - Lead)