Content Innovation, Claims Editing – Specialty Pharmacy

. Monitor and interpret CPT, HCPCS, ICD-10-CM, NCCI, MUE, CMS, specialty society, FDA, drug compendia, NCCN, pricing, and payer policy sources .

Posted 10/15/2026full-timeRemote • United StatesSeniorLead💰 $135,000 - $165,000 per yearWebsite

Tools & technologies

SQL

Key responsibilities & impact

Monitor and interpret CPT, HCPCS, ICD-10-CM, NCCI, MUE, CMS, specialty society, FDA, drug compendia, NCCN, pricing, and payer policy sources
Translate coding rules, clinical guidelines, and reimbursement policy into precise, testable editing logic
Document edit sources, rationale, and scope for traceability and appeals
Maintain content through code updates, policy changes, and performance reviews
Build and maintain specialty drug edits for billing units, NDC-to-HCPCS crosswalks, dosing, maximum units, dose rounding, and JW/JZ modifiers
Cover oncology, immunology, rare disease, biosimilars, and other high-cost therapeutic areas
Use claims data to test concepts, size opportunities, and measure hit rates, false positives, and savings
Review production results to identify gaps, overreach, and missed opportunities
Partner with Product, Engineering, and Data Science on requirements, logic specifications, test cases, and clinical context
Evaluate AI tools and apply expert judgment to AI-generated content
Support client policy review, edit approval, appeals, and content roadmap improvements
Own a content domain and move data-validated concepts into production

What you’ll need

7+ years of experience in claims editing, clinical coding, Payment Integrity, or payer policy, with hands-on experience authoring or validating edits
Active coding credential, such as CPC, CCS, CCS-P, CPMA, or CIC, or a clinical license such as RN paired with deep coding experience
Deep, current knowledge of CPT, HCPCS, ICD-10-CM, modifiers, NCCI, MUEs, coding guidelines, and documentation requirements
Working knowledge of reimbursement methodologies, including fee schedules, DRGs, APCs, and professional and facility billing
Experience sourcing and interpreting CMS manuals, NCDs and LCDs, AMA guidance, and payer policies
Strong analytical skills and comfort working with claims data using SQL, Excel, or similar tools
Experience working with Product, Engineering, Data Science, or other multidisciplinary teams
Clear written communication and ability to explain complex coding and clinical logic to nonclinical audiences
Curiosity about AI tools and willingness to use them in daily content work
At least 3 years of hands-on experience with medical benefit drug billing, coding, or policy, including HCPCS J-codes, NDCs, billing units, drug-related modifiers, and ASP-based reimbursement
Sound judgment and comfort working in a fast-moving build-and-scale environment

Comp & perks