Clinical Content Specialist (Payment Integrity - Drugs & Biological)

Description

Full Job Description

This role is not for 2070 Health.

About CoverSelf:

CoverSelf empowers US healthcare payers with a truly next-generation, cloud-native, holistic, and customizable platform designed to prevent and adapt to the ever-evolving inaccuracies in healthcare claims and payments. By reducing complexity and administrative costs, we offer a unified, healthcare-dedicated platform backed by top VCs like BeeNext, 3One4 Capital, and Z21 Ventures.

Position Overview:

The Clinical Content Specialist – Pharmacy will be responsible for developing and validating high-quality content related to Drugs & Biologicals (D&B) within the US healthcare domain. The role focuses on ensuring accuracy, compliance, and clinical relevance of concepts that impact high-cost medical spend areas such as chemotherapy and specialty drugs. This position requires strong expertise in pharmacy, clinical interpretation, and healthcare coding to support payment integrity and reduce inaccurate reimbursements.

Key Responsibilities:

• Requires a deep understanding of Pharmacy, Clinical aspects

Pharmacy Aspects

• Good understanding of Drugs and Biologicals and their classification
• Awareness of Pharmacy regulatory bodies, like CDSCO,DCGI,DoP
• Generic and Brand drugs awareness
• Dosage determination, medical necessity, safety and compliance.

Clinical Aspects

• Dosage and Administration

• Medical Necessity

• Frequency of Medication

• Contraindication

• Age/Gender

• Adverse Drug Reaction

• Off label usage

• Good understanding of US Healthcare insurance Domain:

• Medical coding and reimbursement guidelines of US healthcare.

• NDC, HCPCS (J-codes), CPT, ICD, Modifiers, Revenue codes, etc.

• CMS, Medicaid guidelines, and payer policies.

• Understanding of CoverSelf Policies and Sub-Policies

• Research and ideation of concepts based on CoverSelf Policies and Medical and pharmacy literatures and drug labels

• Understanding of Medical and Pharmacy Literatures

• Familiarity of Drug Labels, FDA, Well-known Medical journals (Pub-Med, NCBI), CMS, Medicaid guidelines

• Ability to read and Interpret complex of medical and pharmacy literatures

• Extract Rule logic based on CS policies

• Correlation of multiple literatures to arrive at conclusion

Requirements:

• Passionate about working in the pharmacy and clinical domain, with a focus on learning and growth
• Should be passionate about pharmacy and the clinical side
• Strong foundation in pharmacy and clinical concepts, including drugs and biologics
• Demonstrated experience in research work, college thesis, or complex case study analysis
• Strong research mindset with the ability to interpret clinical and medical literature
• Excellent communication, articulation, and interpretation skills
• Ability to translate complex clinical information into clear and structured insights
• Sound clinical knowledge with attention to detail and accuracy

Educational Qualifications:

Pharm.D (Doctor of Pharmacy) – Preferred (Priority)

M.Pharm – Pharmacology / Clinical Pharmacy

Certification Requirements:

CPC or COC certification – highly preferred

Experience:

Freshers with a strong foundation in Pharmacy/Clinical concepts and a research mindset can be considered.

Work Details:

• Location: Jayanagar, Bangalore
• Mode: Work from Office

Benefits:

• Best-in-class compensation
• Health insurance for Family
• Personal Accident Insurance
• Friendly and Flexible Leave Policy
• Certification and Course Reimbursement
• Medical Coding CEUs and Membership Renewals
• Health checkup
• And many more!

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