Lead Clinical Content Strategist

2 weeks ago


Tampa, Florida, United States Apixio Full time
Job Overview

Company Background:

Apixio operates at the crucial intersection of health plans and healthcare providers, striving to develop a premier Connected Care platform aimed at reducing reimbursement discrepancies while promoting high-quality patient care. Our mission is to facilitate the transition towards value-based reimbursement models through innovative solutions that integrate healthcare expertise, AI/machine learning technology, and data-driven analytics.

Position Summary:

The Clinical Content Lead plays a pivotal role in the creation and oversight of our clinical solutions, which encompass Readmissions, Place of Service, Level of Care, and APR-DRG validation clinical concepts. This position demands a deep understanding of healthcare payment methodologies and the criteria for audits and reviews to effectively identify key claims for examination and recovery. A strong background in rule and content development, claims recovery, and APR-DRG expertise is vital. Key responsibilities include:

  • Content Development: Innovate strategies to improve claim selection processes, significantly enhancing payment integrity for clients.
  • Data Analysis: Utilize data analysis skills and organizational acumen to refine proprietary tools, ensuring optimal payment accuracy.
  • Claim Selection Methodology: Apply comprehensive knowledge of claim selection methods to enhance strategies, particularly for inpatient claims.
  • Clinical Solutions Enhancement: Leverage expertise to improve and review clinical solutions related to readmissions and place of service.
  • Collaborative Development: Partner with a diverse team of programmers, operations personnel, product leaders, and auditors to transition DRG process ideas from concept to execution.
  • Regulatory Oversight: Monitor and adjust written rules based on their effectiveness and regulatory updates.
  • Performance Monitoring: Assess the performance of existing and new concepts, making adjustments to optimize outcomes.
  • Analytical Problem-Solving: Employ analytical skills to identify issues and trends, developing and implementing solutions.
  • Policy Development: Formulate departmental policies, processes, and training standards.
  • Support and Evidence Provision: Supply internal and external stakeholders with evidence supporting industry standards and auditing guidelines.
  • Solution Development: Collaborate with cross-functional teams to propose and develop solutions across operations, product, data analytics, and technology.
  • Timeline Management: Establish timelines, communicate progress, and address any roadblocks.
  • Program Deployment: Design and implement effective programs to identify and rectify claims with unusual results.
  • Research and Special Projects: Assist with research initiatives and ad hoc claim reviews as required.
  • Proof of Concept Support: Provide review assistance for proof of concepts or sales support when necessary.

Qualifications:

  • Bachelor's degree in health administration, business, or nursing.
  • Minimum of 5 years of experience in healthcare billing and coding.
  • At least 3 years of experience in claims auditing and recovery auditing.

Experience Requirements:

  • Extensive knowledge of APR-DRG methodology for clinical content development.
  • Experience collaborating within a team, sharing DRG audit process insights with various departments.
  • Familiarity with classification systems, including MSDRG, APR DRG, AP DRG, and outpatient payment systems.
  • Strong analytical skills with a focus on understanding root causes of events and behaviors.
  • Proficient in data utilization and insights.
  • Experience in structuring and executing complex analyses independently.
  • Knowledge of Milliman and InterQual guidelines.
  • Expertise in DRG validation and readmission reviews.
  • Ability to work autonomously while maintaining high-quality standards.
  • In-depth understanding of Medicare and Commercial coding rules and payment systems.
  • Superior knowledge of healthcare coding, billing, reimbursement, and claim adjudication standards.
  • Expertise in clinical criteria documentation requirements.
  • Subject matter expertise in APR-DRG validation, readmissions, and place of service.

Technical Skills:

  • Experience with multiple monitors and remote working environments.
  • Proficient in Microsoft Office Suite, including advanced skills in Excel, PowerPoint, and Word.
  • Familiarity with various software applications and collaboration with development teams.
  • Knowledge of multiple encoder/grouper applications.

Physical Requirements:

  • Ability to sit or stand for extended periods, with occasional bending and reaching.
  • May require lifting up to 25 pounds.
  • Normal range of vision and hearing, with or without accommodations.
  • Position not significantly exposed to adverse environmental conditions.

Compensation:

The salary range for this position is $70,000—$115,000 USD, with total compensation including benefits and variable compensation based on various factors such as skill set and experience.

Company Commitment:

Apixio values diverse experiences and skills, encouraging candidates from all backgrounds to apply. We are committed to equal employment opportunities and take privacy seriously.



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