Job Description

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

Your role in our mission

• Content Development: Work in conjunction with the Medical Directors and Innovation Teams to develop new clinical and coding products. The product focus is identifying overpayments made to provider by insurance companies through data review, data analytics, and application of coding guidelines. Develop innovative strategies to enhance claim selection processes, significantly contributing to payment integrity for our clients.
• Data Analysis and Organization: Leverages data analysis expertise and strong organizational skills to innovate new ideas and new concepts including development of Itemized Bill Review, outpatient claim reviews, other inpatient coding solutions. Performing research and scoping analysis for development of coding and clinical target and edits. 
• Claim Selection Methodology: Utilizes a comprehensive understanding of claim selection methods to refine and execute methodologies that enhance claim selection strategies, particularly focused on inpatient claims.
• Program Performance: Monitor and analyze current and new concepts and target performance. Present results to clinical leadership team. Recommend and implement program changes to improve performance.
• Enhance Clinical and Coding Solutions: Utilize expertise to assist in the enhancement and review of clinical and coding solutions.
• Research: Research industry standard guidelines, State/Federal regulations, and client billing and reimbursement policies, to develop and configure improper payment algorithms
• Regulatory Monitoring: Assess and adjust written rules by monitoring their effectiveness, keeping up with regulatory updates, and making necessary changes. Monitor and research changes in coding guidelines and regulations and determines impact to Gainwell programs.
• Analytical Problem-Solving: Performs detailed analysis of client data to identify areas of high risk and drives concept development in those areas. 
• Policy and Process Documentation: Develop departmental policies, processes, and training standards. Provide internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances.
• Research and Special Projects: Assist with research, special projects, and ad hoc claim reviews as needed.
• Clinical and Coding Content: Develop clinical and coding content that will drive decision-making and documentation for the Clinical Services, Quality and Appeals teams. Develop training and education, and work with clinical teams to make sure that coding content standards are well understood by all levels of the organization.
• SME Support: Maintain expertise in current Gainwell clinical and coding program processes, workflows and outcomes. Provide primary SME support regarding clinical policy, clinical and coding review programs and processes to account management, sales, clients, and clinical teams.
• Client and Sales Support: Provide RFP SME Support. Meet with clients to explain programs and processes, discuss policy concerns, identify issues and develop proactive solutions to problems that clients may be having or anticipate having with Gainwell clinical and coding review programs.

What we're looking for

• 7-10 years reviewing and or auditing ICD 10 CM/PCS, MS-DRG, APR DRG claims and proficient with encoder products. In addition, experience with APC and EAPG preferred. 
• Inpatient Coding Certification Required (i.e CCS, CIC, RHIA, RHIT), and/or other coding certification (COC, CPC) with inpatient coding experience. RN with Coding credentials is preferred.
• 5+ years of experience with healthcare policy, Medicare guidelines and State regulation research and interpretation

• Experience applying inpatient hospital and outpatient facility coding and billing rules

• Deep experience with principals of inpatient and outpatient billing and coding audits with ability to provide Subject Matter Expert (SME) level support to the clinical organization.
• Ability to research State and Federal regulations, clinical policies, coding guidelines to develop and implement policies, clinical/coding resources, and tools to support Gainwell’s Clinical Claim Review products.
• Outpatient and Itemized Bill Review product expertise preferred to support solution development and enhancements.
• Independently perform research and data analysis leveraging claims data to develop new audit strategies, solutions, edits and targets. 

What to expect

• Remote opportunity for candidates within the US

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The pay range for this position is $80,600.00 - $115,200.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies  is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. 

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