Solventum HIS Clinical Analyst – Outpatient Methodology Groupers

SOLVENTUM•Remote - Connecticut, CT

8d•$96,000 - $132,000•Remote

About The Position

Solventum HIS is an international leader in designing and maintaining healthcare payment and quality outcome systems and advancing value-based care. We work closely with Medicare, Medicaid and commercial insurers on hospital, outpatient and population payment models and design quality outcome programs that promote patient safety and reduce avoidable costs. We also support more than ten countries on how they budget and pay for inpatient and outpatient care, and measure healthcare quality. As a hands-on clinical analyst, you will be responsible for the design, development, and maintenance of the Solventum outpatient public and proprietary methodologies, code editors, and software including Tricare, Home Health, IOCE (Integrated Outpatient Code Editor), and EAPG (Enhanced Ambulatory Payment Grouper). These methodologies utilize healthcare data including diagnostic and procedural codes for determining payment and quality in healthcare. You will perform in-depth validation and testing analysis of healthcare data to evaluate methodology behavior and identify anomalies and enhancements. You will serve as a methodology expert contributing and coordinating with the Research team efforts related to the methodologies, and provide input into the prioritization of potential research for enhancements. You will work directly with the Chief Product Owner, Product Owners, and Development team to drive enhancements to the methodologies by translating clinical concepts into clearly documented, executable logic content specifications using existing coding systems (i.e., ICD-10-CM, CPT, and HCPCS) and knowledge of healthcare revenue cycle and outpatient coding and billing. You will collaborate cross-functionally while maintaining accountability with technical, quality, and clinical team members, integrating product concepts to develop software components for each methodology. You will be responsible for maintaining process documentation for the methodologies, producing update summaries and other descriptive documents using C&ER standards and methods.

Requirements

Bachelor or higher (completed and verified prior to start) from an accredited institution
5+ years’ experience in the healthcare industry in one or more of the following: outpatient medical coding and billing operations, outpatient prior authorization or denials management, outpatient healthcare claims and processing optimization, payor claims design and edit management, and outpatient healthcare services research and analytics.
Strong expertise in HCPCS/CPT, ICD-10-CM, and standard claims processing, with additional proficiency in ICD-10-PCS, APC, and DRG classification and reimbursement methodologies.
Significant experience working with excel, databases, and ability to learn computer applications for analysis.
High integrity and work ethic are expected and highly valued.
Must be legally authorized to work in country of employment without sponsorship for employment visa status (e.g., H1B status).

Nice To Haves

Master's degree in health field, clinical informatics, clinical coding, and/or HIM credentials.
Enthusiastic collaborator that energizes and leads others.
Ability to take individual initiative and responsibility for assignments while working independently and in a team environment.
Comfortable in a multicultural, complex, cross-functional, and dynamic work environment, able to prioritize, multi-task, focus on goals, take accountability, and manage time well.
Demonstrated ability to effectively manage frequent context switching across multiple priorities and subject areas within a dynamic work environment.
An ability to effectively communicate ideas, concepts, and information: presenting and training clinical concepts, coding systems and underlying design of patient classification methodologies in healthcare.
The ability to collaborate with a diverse professional team including researchers, healthcare providers, and engineers.
Familiarity with patient classification research and development: Outpatient coding and payment systems Commercial, Medicare and Medicaid environments Risk adjustment Medicare Claims processing and data analysis Experience building payment and quality measures.
Ability to evaluate research questions, analyze results and statistical output and patterns, and document hypotheses and recommendations.
Healthcare software product development experience, bringing products from initial concept to release.
Healthcare payer, delivery or industry experience in healthcare quality, population health, care management.
Familiarity with use of AI for research, analytics and automation of processes.

Responsibilities

Serve as a hands-on clinical analyst, responsible for the design, development and maintenance of the Solventum outpatient public and proprietary methodologies, code editors, and software including Tricare, Home Health, IOCE (Integrated Outpatient Code Editor), and EAPG (Enhanced Ambulatory Payment Grouper).
Perform in-depth validation and testing analysis of healthcare data to evaluate methodology behavior and identify anomalies and enhancements.
Serve as methodology expert contributing and coordinating with the Research team efforts related to the methodologies, provide input into the prioritization of the potential research for enhancements.
Work directly with the Chief Product Owner, Product Owners, and Development team to drive enhancements to the methodologies by translating the clinical concepts into clearly documented, executable logic content specifications using existing coding systems (i.e., ICD-10-CM, CPT, and HCPCS) and knowledge of healthcare revenue cycle and outpatient coding and billing.
Collaborate cross-functionally while maintaining accountability with the technical, quality, and clinical team members, integrating product concepts to develop software components for each methodology.
Responsible for maintaining process documentation for the methodologies, producing update summaries and other descriptive documents using C&ER standards and methods.
Comply with corporate policies, procedures and security standards while performing assigned duties.