Payment Policy Analyst (Remote, North Carolina Based)

Payment Policy Analyst is responsible for managing cross-departmental implementation of changes to payment and billing policies as necessary due to regulatory or contractual changes, or as a result of claims data findings. This position will closely collaborate with the internal Claims department to define requirements and to document those requirements sufficiently to ensure accurate implementation of payment rules within the Plan’s adjudication system. As directed by leadership, he/she will project manage regulatory changes that impact payment methods or rates and help drive analytics to support decision-making.

This is a full-time remote opportunity. There is no expectation of being in the office routinely, however, the selected candidate must be available to come into the office for team or onsite meetings as needed.

Responsibilities & Duties

Payment Policy

• Develops and maintains clinical payment policies and works collaboratively with the Claims department to ensure consistency with the Plan’s adjudication system(s)
• Reviews competitor payment policies, evaluates and recommends changes, and upon approval incorporates such changes into the necessary materials
• Facilitates the Payment Policy Committee and submits recommendations for the development and implementation of new payment policies, or changes to existing payment policies
• Remains current on payment policies by monitoring NCDHHS, EOHHS and CMS websites, listservs, and other sources
• Identifies existing payment practices and upcoming changes, and determines the scope and impact of the change on Plan operations and supports the implementation of changes as necessary
• Serves as the department’s subject matter expert for service limits determination as informed by NCDHHS Clinical Coverage Policies, MCG criteria, Alliance’s Medical Policies, and other accepted industry standards
• Works collaboratively with Medical Economics, Claims, Provider Network, IT, and others as necessary to determine impact of implementing recommended policy changes
• Serves as the organization’s research specialist regarding Medicaid payment policies
• Ensures a consistent understanding of operational changes as they relate to payment policies and their downstream impact within the Claims department

Communication and Support

• Collaborates with and supports Medical Economics, Claims and others as necessary to research and identify opportunities for medical cost savings and payment accuracy; actively participates in initiatives implementation as appropriate
• Develops and implements workforce supports and trainings related to payment policies and other related topics
• Acts as the department liaison with the internal Communication team and other stakeholders as appropriately to assure proper internal and external communication for payment policies and related documentation

Project Management

• Serves as the project manager for the overall activities related to payment policies and the Payment Policy Committee
• Develops and implements adequate work plans for project improvement activities related to payment policies

Minimum Requirements

Required:

Bachelor’s degree in health policy, health services research, social science or a related field and three (3) years of experience evaluating, analyzing, researching, and developing health care services, policies, and programs. Must have five (5) or more years experience in a fast paced, managed healthcare environment and Five (5) or more years experience in claims processing or Payment Policy.

Nationally recognized Coding Certification is required.

Preferred:

Master’s degree in health policy, health services research, social science or a related field and five (5) years of experience evaluating, analyzing, researching, and developing health care services, policies, and programs.

A Coding Certification for Payers (CPC-C) is preferred.

Knowledge, Skills, & Abilities

• Extensive knowledge of ICD-9, ICD-10, CPT and HCPCS coding principles and standards
• Experience in working with Medicaid, Medicare, and commercial coding rules/regulatory requirements
• Ability to interact with and educate internal and external stakeholders
• Strong ability to work independently and use sound judgement to effectively manage projects, identify, mitigate, and escalate potential risks appropriately
• Knowledge of Medicaid state policies preferred
• Detailed oriented and organized
• Strong communication and interpersonal skills

Salary Range

$54,825.00 to $91,375.00/Annually

Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.

An excellent fringe benefit package accompanies the salary, which includes:

• Medical, Dental, Vision, Life, Long and Short Term Disability
• Generous retirement savings plan
• Flexible work schedules including hybrid/remote options
• Paid time off including vacation, sick leave, holiday, management leave
• Dress flexibility