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Medical Necessity Specialist



Hyderabad, Telangana, India
Posted on Friday, September 22, 2023

Join one of the nation’s leading and most impactful health care performance improvement companies. Over the years, Health Catalyst has achieved and documented clinical, operational, and financial improvements for many of the nation’s leading healthcare organizations. We are also increasingly serving international markets. Our mission is to be the catalyst for massive, measurable, data-informed healthcare improvement through:

  • Data: integrate data in a flexible, open & scalable platform to power healthcare’s digital transformation​

  • Analytics: deliver analytic applications & services that generate insight on how to measurably improve​

  • Expertise: provide clinical, financial & operational experts who enable & accelerate improvement​

  • Engagement: attract, develop and retain world-class team members by being a best place to work​

Role: Medical Necessity Specialist

Team: Applications Business Unit / Vitalware

Location: India

Job Profile Summary

The Medical Necessity Specialist has primary responsibility for monitoring and ensuring the quality and integrity of data within a defined focus area. Secondary responsibilities include training and mentoring other team members, guiding the development and evolution of specific workflow processes, contributing to the development of process-specific performance metrics and participating in the hands-on production work of the data team. We’re committed to being the catalyst for massive, measurable, data-informed healthcare improvement.

What you'll own:

  • Ensures that websites and data sources for assigned areas of responsibility are monitored regularly and validates receipt of all available data required to meet client expectations. Examples include but are not limited to the Centers for Medicare & Medicaid Services (CMS), Medicare Administrative Contractor (MAC) websites, and other third-party payer websites for new and updated medical necessity documents and other specific payer policies.

  • Participates in the development and implementation of complex rule-sets designed to accurately display data results in Health Catalyst - VitalWare product applications.

  • Reviews and interprets data using defined rule sets, and then creates and enters code edits or mappings into applicable VitalWare product modules. Primary responsibilities include interpreting payer coverage guidelines, creating accurate diagnosis-to-procedure edits, procedure-to-procedure edits and applicable messages, and entering them into Health Catalyst - VitalWare’s proprietary Medical Necessity Policy Manager.

  • Develops and initiates testing scenarios for team work efforts, evaluates the results, and takes necessary action to resolve discrepancies or ambiguities.

  • Participates in activities designed to measure and improve productivity and ensure achievement of service level agreements.

  • Monitors status of compliance with service level agreements and submits reports to immediate manager on a regularly scheduled basis.

  • Facilitates or contributes to internal discussions focused on workflow process improvement and efforts to optimize the performance of data management software applications.

  • Seeks guidance from immediate manager as necessary to develop or apply complex rule sets and to ensure proper application of rule sets or parsing and mapping guidelines.

  • Remains aware and reports on changes in the regulatory environment that have a direct bearing on assigned scope of data responsibility.

  • Responds to user inquiries and trouble tickets related to data within assigned scope.

  • Collaborates with other team members to identify opportunities for improving overall departmental performance.

  • Participates in continuing education activities to maintain and advance professional skill set.

  • Adheres to company-wide and departmental policies and procedures.

  • Embraces and promotes the general concept of good citizenship throughout VitalWare.

  • Consistently demonstrates a commitment to Health Catalyst’s mission, vision and values when carrying out the duties of this position.

What you'll bring:

  • Capable of researching data that may be unfamiliar and applying sound judgment when making decisions so that rule-sets can be applied correctly and display results are as expected.

  • Able to work independently and address objectives without supervision.

  • Strong customer service and communication skills, i.e., able to handle and resolve issues or objections diplomatically and respectfully.

  • Intermediate to advanced understanding of medical terminology.

  • Familiarity with HIPAA standard code-set definitions and code usage, e.g., ICD, CPT, HCPCS, etc.

  • Intermediate to advanced understanding of human anatomy and physiology to facilitate interpretation of source data.

  • Intermediate or advanced understanding of coding guidelines and principles and critical elements of each code set.

  • Intermediate or advanced understanding or medical billing and reimbursement methodologies.

  • Advanced understanding of data management and the concepts of creating edits and parsing/mapping code sets.

  • Advanced understanding of Microsoft Office applications, including Word, Excel, and Outlook.

  • Any coding certification reflective of formal coding training and the ability to apply learned skills effectively.

Preferred Experience & Education

  • High-school diploma (or GED equivalent) and evidence of ongoing continuing education over the ensuing time period.

  • 1-4 years (5+ preferred) working in an office environment performing duties similar in nature to those of this position.

The above statements describe the general nature and level of work being performed in this job function. They are not intended to be an exhaustive list of all duties, and indeed additional responsibilities may be assigned by Health Catalyst.

Studies show that candidates from underrepresented groups are less likely to apply for roles if they don’t have 100% of the qualifications shown in the job posting. While each of our roles have core requirements, please thoughtfully consider your skills and experience and decide if you are interested in the position. If you feel you may be a good fit for the role, even if you don’t meet all of the qualifications, we hope you will apply. If you feel you are lacking the core requirements for this position, we encourage you to continue exploring our careers page for other roles for which you may be a better fit.

At Health Catalyst, we appreciate the opportunity to benefit from the diverse backgrounds and experiences of others. Because of our deep commitment to respect every individual, Health Catalyst is an equal opportunity employer.