Medical and Payment Policy Analyst

The Medical and Payment Policy Analyst will be responsible for research, coding, and implementation of new and existing Medical and Payment Policies. This analyst will be required to maintain up to date knowledge of changes in medical literature and trends in reimbursement and coding guidelines.

Required:

1. Registered Nurse with a BSN or Bachelor’s Degree in Healthcare related field.
2. Minimum of 3 years of experience in a clinical setting as a nurse, OR minimum of 3 years clinical coding experience, preferably in a payer setting
3. Experience in internet-based research as it relates to peer reviewed literature, societal guidelines, and codes (CPT, HCPCS, ICD or NDC)
4. Ability to work well both independently and collaboratively, in a fast-paced and demanding environment
5. Strong communication and analytical skills, including the ability to write clearly and concisely.
6. Ability to analyze complex data and synthesize it for customer and internal consumption.

Desired:

1. Certified Professional Coder (e.g. CPC, CPC-A, CPC-H, CPC-P) or other related professional coding certification, OR willing to pass certification exam within one year of employment.
2. Familiarity with claims payment and reimbursement methodologies as well as medical policy rules and edits.

Responsibilities;

1. Create new, and revise existing, medical and payment policies so that they align with the current medical literature, and correct coding intitiatives.
2. Reviews and identifies changes to medical policies in order to maintain an accurate and current policy library
3. Assist with research to identify opportunities for new medical policies.
4. Maintain policies in accordance with our internal policy process as well as NCQA guidelines.
5. Works with the internal staff and the provider community to supply coding and clinical expertise for customer inquiries, questions, challenges or appeals of medical policies.
6. Maintains current knowledge-base of industry trends, best practices, applications, procedures and policies.
7. Works with business infomatics to demonstrate that medical and payment policies are effectively improving member quality and provider experience.
8. Participates on committees as assigned.
9. Participates in audits as assigned.