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.

Summary

T he Clinical Product Specialist is responsible for the development and performance of our clinical solutions. This role requires expertise in healthcare payment methodologies and audit and review criteria to target key claims for review and recovery. Proven experience in rule and content creation, claims data analysis, claims recovery, and coding expertise is essential. Key responsibilities include developing new content, analyzing data to support concept development, tracking performance, providing implementation and client support, conducting research, and reviewing claims data as needed. This role requires an expert in clinical areas including payment integrity, with ability to lead development of new solutions to drive the success of our clinical solutions and ensure optimal performance.

Your role in our mission

• Content Development: Work in conjunction with the Medical Directors and Innovation Teams to develop new clinical and coding products. 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. 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.
• Product Readiness: Work with a multi-disciplinary teams of data analytics leaders, operations leads, product leaders, and auditors to bring Clinic and Coding concepts from creation to implementation.
• 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: Demonstrate analytical skills to identify problems and trends, develop solutions, and implement action plans.
• 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

• Bachelor's degree (health administration, business, nursing) OR 10 year of experience in lieu of education
• Registered Nurse with active and unrestricted license
• Deep experience with principals of coding audit, utilization review and payment integrity programs.  Equivalent experience  3+ years in claims auditing and recovery auditing
• Experience with clinical ideation and new clinical content development
• 5+ years of experience with healthcare policy, Medicare guidelines and State regulation research and interpretation.
• 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.   Independently perform research and data analysis leveraging claims data to develop new audit strategies, solutions, edits and targets.

What we're looking for

• This is a full-time permanent regular salaried (W-2) employee position.
  • Monday through Friday work schedule (40 hours per week).
• ​​​​​​​ Upward career advancement is possible and encouraged.
• Health (medical, dental, vision) and paid time off benefits start on day 1 of employment.
• Company match 401K and other benefits available within months of starting.
• Computer for work company-provided.
• For all hybrid and remote positions employees' Broadband Internet connections, should have a minimum speed of 24MBS download and 8 MBS upload . Greater speeds will of course provide better performance.
  • To Test your internet download and upload speed:
    • Go to Google.
    • Search for Internet Speed Test .
• Video cameras must be used during all interviews, as well as during the initial week of orientation if hired.

This position is intended for pipelining. We will accept applications on an ongoing basis.

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#LI-REMOTE

The pay range for this position is $90,000 - $105,000 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 committed to a diverse, equitable, and inclusive workplace. We are proud to be 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), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.

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