*** NOTE : No Visa sponsorships supported ***
Job Description
- This is an individual contributor role. Reporting to the Director, Claims Operations, the Payment Policy Analyst will serve as an internal subject matter expert related to ICO, SCO, and MAPD Medical Payment/Reimbursement policies, payment methodologies and coding, for a wide range of professional, facility, community-based, and behavioral health provider types.
- He/She will be responsible for reviewing Medicare/Medicaid guidelines for the MA and RI states. Responsible for determining the benefits/drawbacks of existing policies, propose suggestions to improve the effects of policies, identify regulatory changes and bring proposed changes to Payment Policy committee meeting.
- Act as a liaison with key internal and external stakeholders to determine needs and goals of policies. Gather data and produce reports on the qualitative and quantitative analysis.
- Analyze market trends and conditions
- Develop and maintain CCA reimbursement policies and support the payment policy and payment integrity team to ensure that CCA policies remain consistent with the Plan’s adjudication system(s) and facilitate Payment Policy committee meetings
- Staff and participate in various work groups and committees to support payment policy development and oversight and provide input into processes and workflows reliant on payment policy outcomes.
- Serve as the department’s project manager for: (1) regulatory information such as proposed and final Medicare and/or Medicaid payment regulations, Medicare Manual updates, and CMS fee schedules; and (2) regulatory issues. Determine the scope and impact of the information/issues and take appropriate action.
- Serve as the company’s payment/reimbursement expert regarding Medicare, Medicaid, and internally-developed payment policies and methodologies.
- Remain current on federal and state payment policies and methodologies; monitor public sources to identify, track, and communicate changes that will affect CCA providers
- Collaborate with stakeholder departments to develop and maintain a centralized location to store payment methodology information.
- Develops implementation plans for the introduction, adoption, or modification of payment policies based upon legislative or regulatory actions or internal decision-making
- Assist contracting and provider relations functions with communication to providers related to payment policies and methodologies
- Working knowledge of regulatory landscape and coding affecting medical payment/reimbursement policies
• Excellent understanding of health care industry and market assessment
• High organizational and time management skills
• Strong analytical and problem-solving skills
• Excellent verbal and written communication skills
• Exceptional team player with a strong ability to contribute positively to a team environment under minimal supervision
• Experience with health care reimbursement
• Experience with ancillary, long term care, and community-based providers preferred
• Strong health policy analytical skills and familiarity with Medicare and MassHealth policies.
• Knowledge and experience of health care reimbursement, public health care programs and reimbursement methodologies (Medicaid and Medicare)
• Working knowledge of health care reimbursement, claims, and data systems preferred
• Applies subject matter knowledge; requires capacity to understand specific needs or requirements to apply skills/knowledge
• Ability to plan, organize, and manage own work; set priorities and measure performance against established benchmarks
• Comfort working with and communicating new policies
• Ability to communicate and work effectively at multiple levels within the company
• Customer service orientation; positive outlook, self-motivated and able to motivate others
• Strong work ethic; able to solve problems and overcome challenges
• Actively participates in the evaluation of own performance.
Must-Haves
- Bachelor's Degree in health care or health care policy development ,
- CPC/COC Certification
- Medicare Advantage experience
- Minimum 5 years of experience in health policy and reimbursement or related field
Nice to have: - Reimbursement methodology experience
- Masters Preferred in Business, Public Health, Public Policy, or related field
Eagle IWS and EJM/ EagleML experience