Claims Payment Policy Lead

Claims Payment Policy Lead Overview Fully Remote Role - Must reside in the Tri-State Area (PA, NJ, or DE) We are seeking a Claims Payment Policy Lead to join our Medical Policy and Health Services team. This role is responsible for developing, maintaining, and implementing enterprise claims payment and reimbursement policies that drive adjudication outcomes, regulatory compliance, medical cost management, and member affordability. This is a strategic policy role focused on policy creation, governance, and operational implementation—not claims auditing or retrospective review. The ideal candidate brings a unique blend of clinical experience, coding expertise, and reimbursement knowledge, with the ability to translate complex regulatory and clinical requirements into actionable payment policies. Key Responsibilities Policy Development & Governance Develop and maintain claims payment and reimbursement policies aligned with regulatory requirements and industry standards. Translate clinical guidelines, coding standards, and reimbursement methodologies into operational payment rules. Support policy governance, review, and approval processes. Cross-Functional Leadership Partner with clinical, coding, claims, compliance, finance, and IT teams to develop and implement policy initiatives. Present policy recommendations and updates to leadership and governance committees. Coding & Reimbursement Expertise Apply knowledge of CPT, HCPCS, ICD-10-CM, and reimbursement methodologies to policy development. Evaluate physician and facility billing practices to ensure policy effectiveness and operational feasibility. Support claims system configuration, testing, and implementation activities. Regulatory & Cost Management Monitor CMS, Medicare, Medicaid, FDA, and commercial payer updates. Analyze claims and utilization data to identify reimbursement trends and cost-saving opportunities. Recommend policy enhancements that improve compliance, efficiency, and affordability. Required Qualifications Bachelor's degree in Nursing, Health Information Management, Healthcare Administration, or related field (or equivalent experience). 3+ years of clinical experience (RN preferred; other clinical backgrounds considered) 3–5+ years of hands-on medical coding experience. Active CPC, CCS, RHIA, or RHIT certification. Strong knowledge of CPT, HCPCS, ICD-10-CM, claims adjudication, and reimbursement methodologies. 3+ years of experience in healthcare reimbursement, claims operations, payer, or revenue cycle environments. Familiarity with CMS, Medicare, Medicaid, and commercial payer reimbursement policies. Preferred Qualifications Experience developing claims payment or reimbursement policies Payer, health plan, or managed care experience Knowledge of physician and facility reimbursement models Experience with policy governance or reimbursement committees