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Lead Assistant Manager

EXL Service -
Chennai, Tamil Nadu

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Job details

Full-time
2 days ago

Qualifications

Knowledge management
Power BI
Content management systems
Tableau
SQL
Medical records
Natural language processing
CPT coding
Scrum
Agile
JSON
Data science
AI
Python

Full job description

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).

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