Clinical Consultant I

Remote role located anywhere in the continental US.

About the role

The Clinical Consultant supports Clinical Services teams in validating quality and process consistency on the CPE editing engine. Provides subject-matter expertise on Coding Validation (CV) to clients and internal stakeholders during planning, implementation, go-live, transition to operational teams, and throughout the contract duration. Collaborates with internal teams to improve CV processes and support, ensuring maximum value and service for clients. Supports internal teams with new policy presentations, appeals management, and validation of quality and process consistency, including customization requests, payment policies, pre/post testing, and UAT testing.

Responsibilities

• Client-facing Coding Validation support:
  • Act as a liaison for clinical information between internal partners and external customers.
  • Provide resources to facilitate client understanding of Coding Validation policies and concepts.
  • Respond to client inquiries in a timely manner in compliance with policy and procedures.
  • Review and analyze CV-related client inquiries and Change Requests for clarity, assess impact on affected policies, and communicate effectively with clients.
  • Provide support and resources to clients for provider abrasion issues.
  • Review and explain CV coding concepts in writing or verbally.
  • Serve as a resource for CV-related quality issues, communicate quality review results, and provide action plans to mitigate future issues in collaboration with the Quality Team.
• Add value to internal teams:
  • Proactively share CV knowledge and experience.
  • Collaborate with Client Teams to develop and maintain excellent client relationships.
  • Provide input from a client-based perspective on edit configuration changes, rule updates, and new editing development.
  • Assist the Clinical Content Team with client feedback on new trends and rule applications.
  • Work with Quality, Training, and Operations Teams to update CV review guidelines, communicate client-specific changes, and address CV issues accurately and timely.
  • Support the Clinical Services team on Coding Validation implementations, including reviewing test claims and internal go-live support.
  • Act as a liaison for the appeals management process.
• Quality support:
  • Participate in CPE Clinical Services quality assurance processes, including pre/post-release testing and other identified areas.
  • Assist Clinical Content Teams with validation and review of client payment policies.
  • Maintain Client Information Workbooks with updated CV review information.
  • Provide support during user acceptance testing in Nucleus.

Requirements

• Education:
  • Associate or Bachelor’s degree in Nursing (active/unrestricted license).
• Licenses & Certifications:
  • Active and unrestricted Registered Nursing (RN) license in state of residence.
  • Professional coder certification (CPC, CPC-H, CPC-P, or CCS-P), RHIT, or RHIA certification.
• Experience:
  • 2+ years of clinical experience as a Registered Nurse.
  • 1+ years of experience in Coding Validation.
  • 1+ years of experience in coding, including professional and outpatient facilities.
  • 1+ years of experience in claims adjudication, medical/payment policy, or utilization review within a managed care or healthcare insurance company, or related experience.
  • 1+ years of experience in customer service or client management in a healthcare setting.

Skills

• Ability to analyze complex data and synthesize it for customer and internal consumption.
• Strong research capabilities and knowledge of CMS guidelines, regulatory compliance, and medical payment policy.
• Proficient with Microsoft Office Suite (Word, Excel, PowerPoint).
• Working knowledge of Cotiviti systems preferred.
• Basic working knowledge of the following applications within 90 days of hire: Nucleus, JIRA, Mantis, MicroStrategy, Tableau.
• Knowledge of medical terminology.
• Detail-oriented with strong analytical and problem-solving skills.
• Ability to handle multiple tasks, prioritize, and meet deadlines in a fast-paced environment.
• Professional with the ability to handle confidential information appropriately.
• Ability to work independently and collaboratively in a remote, cross-functional team environment.
• Strong written and verbal communication and interpersonal skills.
• Computer and technology literate.
• Ability to positively manage stress, such as high work volume and frequent change.
• Flexibility and willingness to participate in an international organization’s processes, including accommodating global time zones.

Working Conditions

• Remote role with up to 10% travel.
• After-hours and/or weekend work may be required for major deliverables or deadlines (not consistent).
• Must provide a dedicated, secure work area with high-speed internet access and office setup.
• Must be able to sit and use a computer keyboard for extended periods.
• Repeating motions involving wrists, hands, and/or fingers may be required.

Pay

Base compensation ranges from $80,000 to $95,000 per year. Specific offers are determined by experience, education, skills, certifications, and business needs.

Benefits

• Medical, dental, vision, disability, and life insurance coverage.
• 401(k) savings plan.
• Paid family leave.
• 9 paid holidays per year.
• 17–27 days of Paid Time Off (PTO) per year, depending on level and length of service.