At the intersection of health plans and providers, Apixio is creating a leading Connected Care platform to minimize reimbursement inaccuracies and high-quality patient care so they can thrive as the industry moves toward value-based reimbursement models.
The combination brings together healthcare expertise, AI/machine learning technology and data-driven analytics solutions to deliver innovative solutions and value to our customers and the healthcare ecosystem. We aim to accelerate the shift toward alternative payment models, while enhancing efficiency and supporting better patient outcomes.
The Clinical Content Lead is responsible for the development and management of our clinical solutions, including Readmissions, Place of Service, Level of Care, and APR-DRG validation clinical concepts. This role requires expertise in healthcare payment methodologies and audit and review criteria to target key claims for review and recovery. Proven experience in rule and content creation, claims recovery, and APR-DRG expertise is essential. Key responsibilities include developing content, tracking performance, providing implementation and client support, conducting research, and reviewing claims as needed for proof of concepts. This role requires an expert in clinical areas in addition to payment integrity, with a keen attention to detail and analytical skills to drive the success of our clinical solutions and ensure optimal performance.
- Develop innovative strategies to enhance claim selection processes, significantly contributing to payment integrity for our clients.
- Leverages data analysis expertise and strong organizational skills to innovate and optimize proprietary tools, ensuring the highest standards of payment accuracy.
- Utilizes a comprehensive understanding of claim selection methods to refine and execute methodologies that enhance claim selection strategies, particularly focused on inpatient claims.
- Utilize expertise to assist in the enhancement and review of readmissions, place of service, and other clinical solutions.
- Work with a multi-disciplinary team of programmers, operations staff, product leaders, and auditors to bring DRG process ideas from creation to implementation.
- Assess and adjust written rules by monitoring their effectiveness, keeping up with regulatory updates, and making necessary changes.
- Monitor performance of current and new concepts and continue to adjust to enhance performance and output.
- Demonstrate analytical skills to identify problems and trends, develop solutions, and implement action plans.
- Develop departmental policies, processes, and training standards.
- Provide internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances.
- Collaborate with a multi-disciplinary team to suggest solution development, including operations, product, data analytics, and technology.
- Set timelines and ensure communication on progress, tracking delivery, and escalating roadblocks or dependencies.
- Design and deploy effective programs/solutions to identify and correct claims with aberrant results, providing feedback to resolve root causes.
- Assist with research, special projects, and ad hoc claim reviews as needed.
- When necessary, provide review support for proof of concepts or sales support.
- Bachelor’s degree (health administration, business, nursing)
- Equivalent experience of 5+ years in healthcare billing and coding
- Equivalent experience of 3+ years in claims auditing and recovery auditing
- Extensive experience in APR-DRG methodology for clinical content development
- Proven experience working within a team, sharing DRG audit process knowledge with sales, marketing, and development teams
- Proven knowledge of classification systems, including MSDRG, APR DRG, AP DRG, and outpatient payment systems such as APCs and EAPGs
- Demonstrated curiosity and mastery in understanding the root cause of events and behaviors
- Strong experience in data utilization and insights
- Experience independently structuring and executing complex analyses
- Familiarity with Milliman and InterQual guidelines
- Expertise in DRG validation
- Experience in production and team management
- Experience with Readmission reviews
- Ability to work efficiently and effectively with minimal supervision
- High standards of quality and attention to detail
- Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems
- Superior knowledge of healthcare coding, billing, reimbursement, and claim adjudication standards and procedures
- Expert knowledge of clinical criteria documentation requirements
- Subject matter expertise in APR-DRG validation, Readmissions, and Place of Service
- Experience working with multiple monitors
- Proven success in a remote working environment
- Proficient in Windows office systems, including the full Microsoft Suite and Teams
- Advanced skills in Microsoft Office (Excel, PowerPoint, Word)
- Experience with various software applications and collaboration with development teams
- Familiarity with multiple encoder/grouper applications
- Ability to sit or stand for long periods, with occasional stooping and reaching
- May require lifting up to 25 pounds
- Requires a normal range of vision and hearing, with or without accommodations
- Position is not substantially exposed to adverse environmental conditions
The salary range below is for Base Salary. Total compensation also includes benefits and variable compensation. Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee’s geographic location.
Base Compensation
$70,000—$115,000 USD
- Meaningful work to advance healthcare
- Competitive compensation
- Exceptional benefits, including medical, dental and vision, FSA
- 401k with company matching up to 4%
- Generous vacation policy
- Remote-first & hybrid work philosophies
- A hybrid work schedule (2 days in office & 3 days work from home) ()
- Modern open office in beautiful San Mateo, CA; Los Angeles, CA; San Diego, CA; Austin, TX and Dallas, TX
- Subsidized gym membership
- Catered, free lunches
- Parties, picnics, and wine-downs
- Free parking
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What We Do
Apixio is the Connected Care Platform at the intersection of health plans and providers. Our AI technology and flexible services power risk adjustment, payment integrity, and care delivery programs using centralized patient health profiles, data-driven insights, and seamless workflows. With Apixio, healthcare organizations can streamline operations, ensure accurate payment, and uncover critical patient insights—building a resilient foundation for success as the industry moves toward value-based reimbursement models.
At Apixio, we strive for excellence in everything we do and understand that success is not built overnight but is the collective effort of smart people asking the right questions, taking calculated risks, and delivering innovative industry-leading solutions.
Apixion’s are motivated, resourceful, intelligent, and scrappy trouble-shooters who work hard, play hard, and are committed to making an impact in our industry and in our communities. Our team is dedicated to hiring quality candidates of diverse backgrounds who can share their ideas and experience to create a holistic client and employee experience that is respectful of our company mission, and reflective of the individual talents that each Apixion brings with them. With Apixio you can expect the best because we are passionate and committed to delivering the best. We celebrate each success, big or small, and aim to help each Apixion reach their full potential.
At Apixio, our culture is one that encourages diversity and looks to expand it constantly. Our employees make our inclusive culture what it is and we provide the tools and resources they need to feel empowered and supported. Apixion’s don’t just talk the talk, they walk the walk with our employee ran groups that focus on diversity and inclusion, community give back, and professional and personal growth.
Why Work With Us
Smart people who are passionate about making an impact yet we leave our egos at the door
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