Claims Payment Policy Lead

Claims Payment Policy Lead

Our direct client is looking for a Claims Payment Policy Lead for remote work. Position is remote but candidate must reside in the tri-state area. The Claim Payment Policy Lead is responsible for generating policy driven innovative medical cost opportunities as well as investigating, reviewing, and applying clinical and/or coding expertise in the development and application of reimbursement or medical policies.

Duties and responsibilities include leading cross-functional collaborations with key business areas to generate policy driven innovative medical cost savings ideas, validating feasibility, and executing successful implementation. Monitoring industry trends, regulatory changes, and reimbursement practices to ensure compliance and alignment with organizational goals. Developing and maintaining claim payment policies that reflect nationally recognized reimbursement practices in accordance with company benefit, contracting and reimbursement structures, state and federal mandates and other appropriate sources. Presenting policy bulletins to appropriate workgroups and committees and revising documents according to recommendations. Applying appropriate coding sources to recommend and develop comprehensive code assignments in accordance with established coding guidelines. Developing, preparing and presenting detailed business requirement documents to support policy and coding initiatives. Evaluating and analyzing utilization patterns and other sources of information to make recommendations for appropriate and cost-effective utilization. Developing business cases to assist with decision making for assigned initiatives. Mentoring other staff and serving as coding and/or clinical SME and representing the department in a variety of forums. Interacting with all levels of associates and management within the company and with outside contractors, consultants and other organizations. Performing additional related duties as assigned.

Knowledge, skills, and abilities required include a bachelor's degree in relevant discipline or equivalent work experience. Current coding certification (CCS, CPC, RHIA, RHIT), or current coding certification in combination with a clinical licensure (e.g., RN). Minimum of five years related work experience with evidence of a broad base of knowledge and application of the revenue cycle management process and medical code sets, including CPT, HCPCS, and ICD-10. Knowledge of healthcare reimbursement concepts, health insurance business, industry terminology, and regulatory guidelines. Familiarity with Medicare rules and regulations. Excellent organizational, time management, presentation, verbal, written and analytical skills and demonstrated ability to develop and lead cross-functional teams. Must be able to work independently, prioritize workload, meet deadlines, and to assess the criticality of issues.

Benefits include a competitive compensation package that includes pay rate of $50-55/hr W2, medical for full time employees, dental and vision insurance, life insurance, short-term disability, long-term disability, etc.