Clinical Content Specialist – Payment Integrity (Drugs & Biologics)

About the role

CoverSelf is seeking a Clinical Content Specialist focused on Payment Integrity for Drugs & Biologics. The role will develop and validate high-quality clinical content that supports accurate reimbursement for high-cost therapies such as chemotherapy and specialty drugs within the US healthcare system.

Key responsibilities

• Research, interpret, and synthesize drug and biologic literature, FDA labels, and medical journals to create accurate content rules.
• Validate dosage, medical necessity, safety, contraindications, and off-label usage for drugs and biologics.
• Apply US healthcare coding standards (NDC, HCPCS/J-codes, CPT, ICD, modifiers, revenue codes) to ensure compliance with CMS, Medicaid, and payer policies.
• Extract and document rule logic based on CoverSelf policies and external guidelines.
• Collaborate with cross-functional teams to align content with payment integrity objectives.

Required profile

• Strong passion for pharmacy and clinical domains with a desire for continuous learning.
• Solid foundation in pharmacology, drugs, and biologics, preferably a Pharm.D or M.Pharm.
• Demonstrated research experience through theses, case studies, or publications.
• Excellent written communication and ability to translate complex clinical information into clear insights.

Required skills

• In-depth knowledge of US medical coding systems: NDC, HCPCS (J-codes), CPT, ICD, modifiers, revenue codes.
• Familiarity with CMS and Medicaid reimbursement guidelines and payer policies.
• Ability to interpret FDA drug labels, PubMed/NCBI articles, and other medical literature.
• Preferred CPC or COC certification.