Mode: Hybrid / Onsite Shift: US hours (as applicable) 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