Senior Clinical Tool Specialist

4 days ago


Manila, National Capital Region, Philippines Seven Seven Global Services, Inc. Full time

Job Summary:

  1. Lead and support the research, development, and enhancement of clinical tools such as groupers, classifiers, and patient segmentation systems to optimize clinical risk management.
  2. Assess and refine clinical tools, including diagnosis-related groupers, disease staging tools, and risk scores, ensuring accuracy and relevance for healthcare analytics.
  3. Provide clinical expertise in claims data analysis to derive actionable insights that drive improvements in cost containment, quality, and clinical pathways.
  4. Collaborate with internal teams and external stakeholders to integrate clinical tools into various business processes and support customer engagement.
  5. Contribute to the development of clinical pathways and support clinical coding teams in maintaining and updating classification systems to enhance healthcare decision-making.

Requirements:

  1. A medical graduate (MBBS) with a minimum of 2 years of post-qualification clinical experience.
  2. A minimum of 5 years of healthcare insurance experience – payor, provider, or regulator.
  3. Qualifications or training in Health informatics, clinical coding or Health Administration would be preferred.
  4. Strong understanding of healthcare-specific data and health insurance claims is required.
  5. Expertise in clinical data analysis, claims sample checks, and validation of tools and groupers is essential.
  6. Extensive experience with diagnosis-related groupers (DRG) and a solid foundation in clinical coding is a must.
  7. Familiarity with international clinical coding terminologies and ontologies, such as SNOMED-CT, LOINC, ICD-10/ICD-11, CPT, and HCPCS, is highly valued.
  8. Knowledge of APAC regional coding practices and guidelines is preferred.
  9. Proficiency in risk adjustment tools, disease episode groupers, patient risk scores, and disease staging tools is highly desirable.
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