Job Description: We are seeking an experienced Clinical Coding Subject Matter Expert (SME) to support the development, validation, and continuous improvement of AI-powered solutions across its Healthcare Payer Practice. In this role, you will work closely with AI engineers, product managers, and client-facing teams to ensure that our solutions reflect real-world coding standards, payer policies, and clinical accuracy. The ideal candidate brings deep hands-on experience in ICD-10-CM/PCS, CPT/E&M, and DRG-based inpatient coding, with a strong understanding of payer adjudication logic and prior authorization workflows.
Responsibilities: SME & Clinical Advisory
- Serve as the primary clinical coding advisor for AI product teams, providing guidance on ICD-10-CM/PCS, CPT/E&M, and DRG/inpatient coding rules, conventions, and edge cases.
- Interpret and apply CMS guidelines, LCD/NCD policies, AHA Coding Clinic guidance, and payer-specific policies to AI model training and validation activities.
- Partner with Legal and Compliance teams to ensure coding logic adheres to applicable federal and state regulations, including HIPAA and CMS standards.
- D rive cross-functional alignment on coding standards and AI solution design .
Product development and testing Support:
- Collaborate with AI engineers and data scientists to define coding logic, decision trees, and clinical criteria used in AI model development and prompt engineering.
- Translate complex clinical coding rules into structured, machine-readable formats (e.g., YAML, JSON decision trees) for consumption by AI pipelines.
- Contribute to the development of synthetic test cases and clinical scenarios for model evaluation across CPT codes, DRG groupings, and authorization pathways.
- Support the development of quality assessment frameworks to evaluate whether AI outputs align with payer coverage policies and coding guidelines.
Data & Performance Tracking
- Validate AI recommendations against gold-standard coding outcomes; identify discrepancies, document findings, and work with engineering teams on remediation.
- Develop and maintain coding accuracy benchmarks, KPIs, and evaluation rubrics for ongoing model performance monitoring .
Knowledge Management & Training
- Develop training materials and conduct knowledge transfer (KT) sessions for AI engineers, QA analysts, and client-facing teams on coding concepts and clinical & billing workflows - claims adjudication, adjustment etc
- Stay current with coding guideline updates; proactively assess and communicate the impact of coding changes on AI solutions
Supporting Pre-Sales Solution Design
- Support pre-sales and solution design activities by contributing clinical domain expertise to proposals, demos, and proof-of-concept engagements.
Qualifications: Required Qualifications
- 7+ years of hands-on clinical coding experience in a U.S. healthcare setting, with demonstrated expertise in ICD-10-CM/PCS, CPT/E&M, and DRG/inpatient coding.
- Active credential from AAPC or AHIMA (CPC, CCS, RHIA, RHIT, or equivalent)
- Strong working knowledge of CMS reimbursement methodologies, payer prior authorization processes, and claims adjudication and adjustment rules.
- Familiarity with healthcare data standards including ICD-10, CPT, HCPCS, NPI, and claims data formats (837P/837I)
- Experience reviewing medical records, interpreting clinical documentation, and applying coding guidelines to complex patient scenarios.
- Demonstrated ability to communicate clinical concepts clearly to non-clinical stakeholders including engineers, product managers, and business analysts.
Bonus & Preferred Qualifications
- Experience working in AI, health IT, or digital health product environment particularly in roles supporting model validation, UAT, or clinical NLP/ML systems.
- Hands-on experience reviewing or validating outputs from AI-assisted or automated coding systems, including identifying model errors or hallucinations and providing structured feedback to improve system performance over time.
- Exposure to FHIR-based data structures, CDS Hooks, and structured clinical data formats used in payer workflows.
- Background in payment integrity, clinical auditing, RAC/MAC audit response, or coding compliance programs.
- Familiarity with coding compliance edit frameworks, claim editing logic, and standard payer editing conventions (e.g., duplicate billing, bundling, unbundling, and modifier validation); experience applying or reviewing such edits in a payer or payment integrity context is a plus.
- Experience writing or reviewing structured policy criteria against payer-specific coverage policies and clinical guidelines.
- Background in Clinical Documentation Improvement (CDI) for inpatient DRG-impacting conditions.
- Prior experience leading or managing a clinical coding team including mentoring coders, conducting audits, overseeing productivity and quality metrics, or managing coding operations for a department or business unit
- Basic proficiency in SQL, Python, or data visualization tools (Tableau, PowerBI) to perform independent product data analysis
- Familiarity with agile/scrum delivery methodologies and comfort participating in sprint ceremonies (backlog grooming, sprint planning, retrospectives).
