Key Responsibilities: • Analyze and interpret concepts to ensure accurate configuration in line with medical coding, billing, and reimbursement guidelines. • Analyze medical coding, reimbursement guidelines and configure logic to support accurate concept execution. • Conduct in-depth reviews of contracts, policies, and federal/state regulations to formulate edit requirements. • Apply industry coding guidelines to claims processes effectively. • Demonstrate experience in analyzing and resolving coding issues for payment integrity purposes. • Analyze, develop, and implement system configurations. • Collaborate with subject matter experts (SMEs) and technical teams to translate regulatory and policy requirements into functional edit specifications. • Translate editing logic into platform configurations with support from SMEs, and stakeholders to ensure clear understanding and configuration of concepts. • Collaborate with cross-functional teams to assess configuration needs and implement appropriate solutions. • Assist in developing and maintaining payment integrity policies and procedures. • Review configurations to ensure completeness and accuracy based on the medical coding and billing guidelines. • Troubleshoot and perform root-cause analysis for edit logics not functioning as intended. • Effectively pinpoint configuration discrepancies and ensure concepts are deployed successfully and on schedule. • Audit and validate concepts against healthcare guidelines; identify and address gaps with upstream teams. • Conduct rigorous testing to verify concept accuracy and performance across outpatient, professional, and inpatient claim scenarios adhering to the coding guidelines. • Perform acceptance testing to validate configuration accuracy. • Stay updated with industry regulations and compliance requirements to ensure the configuration process adheres to relevant standards. • Perform duties independently with a high level of accuracy and professionalism. • Exhibit detail-oriented mindset with a focus on quality and accuracy in concept configuration & testing. • Familiarity with AI tools and prompt engineering to support medical content development, automation of policy logic, and Concept generation o Design and optimize prompts for large language models (LLMs) to generate accurate and clinically relevant medical content. o Experience in utilize AI tools (e.g., Gemini, NotebookLLM, ChatGPT, Claude, Perplexity, Grok, Bard, or custom LLMs) to assist in ideation, content creation, review, summarization, and validation. Key Skills: • Domain Expertise in US Healthcare Medical Coding, Medical Billing, Payment Integrity, Revenue Cycle Management (RCM), Denials Management. • Codeset Knowledge like CPT/HCPCS, ICD, Modifier, DRG, PCS, etc. • Knowledge on policies like Medicare/Medicaid Reimbursement, Payer Payment Policies, NCCI, IOMs, CMS Policies etc. • Proficiency in Microsoft Word and Excel, with adaptability to new platforms. • Excellent verbal & written communication skills. • Excellent Interpretation and articulation skills. • Strong analytical, critical thinking, and problem-solving skills. • Willingness to learn new products and tools. • Strong time management skills and ability to meet deadlines. Qualifications: Education & Certification (one of the following required): • Bachelor of Science in Nursing (B.Sc. Nursing). • Pharmacist Degree (B.Pharm, M.Pharm or PharmD). • Life science Degree (Microbiology, Biotechnology, Biochemistry, etc). • Medical Degree (e.g., MBBS, BDS, BPT, BAMS etc). • Other Bachelor’s Degree with relevant experience. Certification Requirements: • Candidates with certifications like CPC, CPMA, COC, CIC, CPC-P, CCS, or any specialty certifications from AHIMA or AAPC will be given preference. • Additional weightage will be given for AAPC specialty coding certifications. Experience: • 0-1 years of experience in Payment Integrity, Medical Coding, Denial Management. • Experience in payment integrity, claims processing, or related functions within the US healthcare system. • Experience in denial management, retrospective payment audits, or medical coding. • Familiarity with Medical coding guidelines, such as ICD, CPT, Modifiers, Medicare, Medicaid, or commercial payer guidelines. Work Location: Jayanagar - Bangalore. Work Mode: Work from Office.