Senior Clinical Tool Specialist
4 days ago
Job Summary:
- Lead and support the research, development, and enhancement of clinical tools such as groupers, classifiers, and patient segmentation systems to optimize clinical risk management.
- Assess and refine clinical tools, including diagnosis-related groupers, disease staging tools, and risk scores, ensuring accuracy and relevance for healthcare analytics.
- Provide clinical expertise in claims data analysis to derive actionable insights that drive improvements in cost containment, quality, and clinical pathways.
- Collaborate with internal teams and external stakeholders to integrate clinical tools into various business processes and support customer engagement.
- Contribute to the development of clinical pathways and support clinical coding teams in maintaining and updating classification systems to enhance healthcare decision-making.
Requirements:
- A medical graduate (MBBS) with a minimum of 2 years of post-qualification clinical experience.
- A minimum of 5 years of healthcare insurance experience – payor, provider, or regulator.
- Qualifications or training in Health informatics, clinical coding or Health Administration would be preferred.
- Strong understanding of healthcare-specific data and health insurance claims is required.
- Expertise in clinical data analysis, claims sample checks, and validation of tools and groupers is essential.
- Extensive experience with diagnosis-related groupers (DRG) and a solid foundation in clinical coding is a must.
- Familiarity with international clinical coding terminologies and ontologies, such as SNOMED-CT, LOINC, ICD-10/ICD-11, CPT, and HCPCS, is highly valued.
- Knowledge of APAC regional coding practices and guidelines is preferred.
- Proficiency in risk adjustment tools, disease episode groupers, patient risk scores, and disease staging tools is highly desirable.
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