About CoverSelf:CoverSelf empowers US healthcare payers with a truly next-generation, cloud-native, holistic, and customizable platform designed to prevent and adapt to the ever-evolving inaccuracies in healthcare claims and payments. By reducing complexity and administrative costs, we offer a unified, healthcare-dedicated platform backed by top VCs like BeeNext, 3One4 Capital, and Z21 Ventures.
Position Overview:This role focuses on developing clinical content, payment integrity rules, and code edit solutions. The Clinical Content Specialist will translate clinical guidelines and payer policies into business logic, algorithms, and rule frameworks for automated claims validation.
Key Responsibilities:Develop and maintain payment integrity rules, edits, and policies Design clinical logic & algorithms for claims validationTranslate CMS guidelines → business rulesBuild code edit solutions to detect incorrect paymentsConduct research on medical policies and reimbursement methodologiesEnhance and maintain policy libraries and rule frameworksSupport semi-automated claims review systems