Clinical Content Strategy Manager / Payment integrity, Analytics & Strategy Manager
Position Summary
We are seeking a highly analytical healthcare professional to lead strategic editing initiatives through market intelligence, coding and reimbursement analysis, claim data mining, and healthcare trend analytics. This role will serve as a critical bridge between data, clinical policy, payment integrity strategy, and product development, identifying opportunities for new clinical edits, policy enhancements, and revenue protection programs across Commercial, Medicare, and Medicaid populations.
The ideal candidate possesses deep expertise in payment integrity and clinical editing, combined with strong analytical capabilities to transform claim data, coding updates, regulatory changes, and emerging market trends into actionable content and editing strategies. This role will partner closely with Content, Product, Clinical, Technology, and Client teams to drive the development and prioritization of next-generation payment integrity solutions.
Key Responsibilities
Strategic Editing Opportunity Development
- Identify, evaluate, and prioritize new clinical editing opportunities through analysis of claim data, provider billing patterns, reimbursement trends, and market intelligence.
- Develop data-driven recommendations for new payment integrity initiatives that improve savings, payment accuracy, and client outcomes.
- Monitor emerging healthcare trends, utilization patterns, and regulatory changes to identify areas for content and policy expansion.
- Support long-term editing and policy roadmaps through market and competitive analysis.
- Ad hoc project management
Claims Data Mining & Analytics
- Analyze large-scale medical and facility claims datasets to uncover inappropriate billing patterns, reimbursement inconsistencies, and emerging payment integrity opportunities.
- Perform quantitative analysis to estimate potential financial impact, savings opportunity, provider abrasion risk, and implementation feasibility.
- Develop predictive and retrospective analyses that support strategic decision-making and content prioritization.
- Create dashboards, reports, and executive summaries that communicate analytical findings to leadership and clients.
Clinical Policy & Editing Strategy
- Optimize workflows that translate healthcare regulations, coding changes, reimbursement updates, and clinical guidance into actionable policy recommendations.
- Evaluate opportunities generated from:
- CPT® updates
- ICD-10 coding changes
- HCPCS revisions
- CMS policy changes
- Medicare and Medicaid guidance
- Commercial payer reimbursement trends
- Client-specific utilization patterns
- Partner with clinical and content teams to define business requirements and implementation strategies for new edits.
Market Intelligence & Industry Research
- Monitor industry publications, coding updates, CMS releases, payer bulletins, and reimbursement guidance.
- Assess competitive market offerings and identify gaps that can be addressed through innovative editing and policy solutions.
- Evaluate potential partnerships, third-party content opportunities, and emerging healthcare technologies that support payment integrity initiatives.
- Recommend strategic investments based on market demand, client needs, and projected value.
Cross-Functional Leadership
- Collaborate with Content, Product, Engineering, Clinical, and Client Success teams to advance strategic initiatives from concept through implementation.
- Support prioritization of editing opportunities based on client impact, market demand, implementation complexity, and return on investment.
- Present opportunities, findings, and recommendations to senior leadership and client stakeholders.
- Act as a subject matter expert for healthcare reimbursement trends, claims analytics, and payment integrity strategy.
Required Qualifications
Education
- Bachelor’s degree or equivalent
Experience
- 5+ years of healthcare analytics, payment integrity, clinical policy, or clinical editing experience.
- Demonstrated end-to-end experience supporting Commercial, Medicare, and Medicaid payment integrity programs.
- Experience identifying and developing new editing opportunities through data analysis and clinical policy review.
- Proven ability to translate complex healthcare data into strategic recommendations.
Healthcare Knowledge
Strong understanding of:
- Medical and facility claim processing
- Payment integrity methodologies
- Clinical editing systems
- Revenue cycle management
- Medicare and Medicaid reimbursement methodologies
- Commercial Payer Policy Frameworks
- Clinical policy development
- Claims auditing and validation
Technical Skills
- AI enabled mindset
- Advanced SQL skills.
- Experience working with large healthcare claims datasets.
- Strong analytical and visualization skills using data mining tools and Excel
- Familiarity with Python, SAS, or other healthcare analytics platforms
Coding & Reimbursement Expertise
Working knowledge of:
- ICD-10-CM
- CPT
- HCPCS
- DRG
- APC
- NCCI
- CMS payment methodologies
- National and local coverage determinations
- Provider billing and coding practices
Preferred Qualifications
- Certified Professional Coding (CPC) certification
- Project Management Professional (PMP) certification
Success Measures
The successful candidate will:
- Develop a sustainable pipeline of high-value editing opportunities.
- Identify new payment integrity initiatives through market intelligence and data mining.
- Improve prioritization of content investments using data-driven methodologies.
- Deliver actionable trend analysis that supports strategic product and policy expansion.
- Influence organizational strategy through insights derived from claims analytics, coding updates, and reimbursement intelligence.
- Become a trusted advisor for emerging payment integrity opportunities and healthcare market trends.
Ideal Candidate Profile
This role is best suited for someone who enjoys answering questions such as:
- What editing opportunities are emerging from current client claim data?
- Which coding updates create new payment integrity opportunities?
- Where are providers billing differently than expected?
- What market trends should drive our next policy investments?
- Which initiatives will generate the greatest value for our clients?
- How should strategic editing resources be prioritized to maximize impact?