Associate Claims Validation Analyst

About Rialtic

Rialtic is an enterprise software platform empowering health insurers and healthcare providers to run their most critical business functions. Founded in 2020 and backed by leading investors including Oak HC/FT, F-Prime Capital, Health Velocity Capital and Noro-Moseley Partners, Rialtic's best-in-class payment accuracy product brings programs in-house and helps health insurance companies gain total control over processes that disparate and misaligned vendors have managed. Currently working with leading healthcare insurers and providers, we are tackling a $1 trillion problem to reduce costs, increase efficiency and improve quality of care. For more information, please visit www.rialtic.io.

The Role

As a Associate Claims Validation Analyst with Rialtic you’ll research and interpret CMS, CPT/AMA, and other major payer policies in accordance with healthcare coding and regulatory requirements. You’ll identify common error areas that can be made into automated software logics that prevent overpayments from occurring. You’ll take your edits from concept to specification and then through review, testing and finally data validation - along the way you’ll collaborate with some of the smartest minds in healthcare policy and technology.

Your goal every day is to develop claims editing logics that promote payment accuracy and transparency across Medicaid, Medicare, and commercial lines of business. You’ll increase your revenue cycle acumen as you identify ways to turn resource excerpts into claims processing rules that educate payers and providers on why a claim should not be paid.  This is an exciting opportunity if you are interested in taking your healthcare experience and growing your technical skills by gaining advanced knowledge in the SaaS healthcare tech space.

You will:

• Review healthcare policy (Medicaid manuals, fee schedules, CCI, OIG Alerts, LCAs/LCDs, NCDs, Medicare manuals, etc.) for coding and billing guidelines that you will interpret and use data validation to ensure the policy and specs align. 
• Work with the concept creation team who create billing edits that provide clients with monetary savings and promote coding accuracy, to ensure accuracy and provide feedback on their edits. 
• Ensure that the structural design follows the policy intent by using data analysis.  
• Build unit tests to verify the functionality of the edits
• Apply revenue cycle, coding, and billing expertise to interpret policy based on correct coding, billing, and auditing guidelines
• Provide in-depth research on regulations and support edits with official documents
• Validate if edits are working as intended and support decisions with validation data
• Maintain current industry knowledge of claim edit references including, but not limited to: AMA, CMS, NCCI
• Collaborate with the Content, Engineering & Data teams to develop, adjust, and validate edits
• Provide subject matter expertise on several professional claims top error areas in coding and billing across multiple specialties
• Independently meet weekly productivity and quality goals
• Be a self-starter and remain driven while independently working remotely.

You have:

• 4+ years of professional experience in Healthcare, familiar with medical coding terminology and claims
• Experience working for a payer or editing vendor.
• Payment accuracy experience with prepayment or post-payment knowledge
• Proficient Computer skills: Ability to self-learn Google Workspace, Amazon Workspace, Jira, and other software with minimal guidance
• Collaboration Skills: Ability to communicate & collaborate with different departments such as Engineering & Product teams.

Nice to haves:

• Nationally recognized coding or billing credentials: CPC, CCS-P, RHIA, CCS, CCS-P, CPB
• SQL query-building and lookup skills for claims data analysis and data mining for editing opportunitiesExperience reading and analyzing Medicare/Medicaid data and policy, which includes fee schedules, CCI, OIG Alerts, LCAs/LCDs, NCDs.
• Experience reading Medicare/Medicaid policies and applying industry coding guidelines to claim processes
• Reading updated policy (e.g., CPT, Medicare, Medicaid) and updating existing payment accuracy guidelines (Maintenance)

We are headquartered in Atlanta, but we are remote-friendly.

Don’t meet every single requirement?

Studies have shown that women and people of color are less likely to apply to jobs unless they meet every single qualification.

At Rialtic, we are dedicated to building a diverse, inclusive and authentic workplace, so if you’re excited about this role but your experience doesn’t align perfectly with every qualification in the job description, we encourage you to apply anyway. You may be just the right candidate for this or other roles.