Policy & Implementation Analyst

Policy & Implementation Analyst

Telecommute Option - Must reside in ID, OR, UT or WA

WHO WE NEED

The Policy and Implementation Analyst uses Medical coding knowledge and experience and evaluates, recommends and implements clinical editing solutions to assure accurate outcomes consistent with medical and reimbursement policy and financial targets. This role develops and executes implementation plans to include system updates, business process changes and timely communication. The position develops, maintains and publishes reimbursement policy.

Preferred Key Experience:

Clinical knowledge (Understands clinical reviews)

Understanding of claims, billing and coding

Facets/claims systems in appeals, SIU

Claims processing, claims configuration roles

Understanding of Medical and reimbursement policies

CPC Certified or willing to get CPC Certified as condition to position.

Normally to be proficient in the competencies listed below

Policy and Implementation Analyst would have a Bachelor's degree in Business Administration or a related field and 3 years of experience in a healthcare related environment utilizing analytical skills or an equivalent combination of education and experience.

Required Licenses, Certifications, Registration, Etc.

Current licensure or professional certification relevant to the work (coding certification) is preferred.

YOUR ROLE:

Facilitates development, understanding and documentation of business requirements related to policy implementation and clinical editing.

Performs analysis in the design and implementation plans to support new and revised medical and reimbursement policies.

Responsible for maintaining online documentation for accurate and uniform administration of medical and reimbursement policy.

Coordinates the implementation of new and revised online reference materials and technical documentation.

Communicates policy and edit decisions to internal and external customers in a clear and concise manner.

Creates configuration instructions for clinical edits and preauthorization flags to support medical and reimbursement policy and ensure accurate implementation in multiple claims editing systems.

Tracks, coordinates and oversees medical and reimbursement policy and related clinical edit and coding issues through the implementation process.

Collaborates with other departments to coordinate system implementations, process changes, investigate claims adjudication and member or provider inquiries.

Collaborates with medical directors to ensure clinically appropriate polices and edits.

Identifies data necessary for project, analyzes and transforms data into practical information for communication to stakeholders to drive and support decisions.

Designs and develops testing plans that ensure all key areas are tested sufficiently for successful production results.

Develops reimbursement policies and coordinates reimbursement policy development to include identification of issues, policy research and development, policy approval, policy implementation and policy documentation and education.

WHAT YOU BRING:

Ability to communicate effectively, verbally and in writing.

Understanding of claims processing to evaluate implementation needs

Demonstrated analytical ability to identify problems, develop solutions and implement a chosen course of action.

Ability to present issues, lead and/or participate in discussions and develop conclusions with internal and external medical professionals and other experts.

General computer skills (including use of Microsoft Office, Outlook and internet search).

Familiarity with health care documentation systems.

Proven ability to perform and manage analytical tasks/projects with the ability to work independently.

Demonstrated knowledge of the following: CMS reimbursement and medical policies; Medicare products; Procedural and diagnostic coding; and the national Resource Based Relative Value Schedule.

Serves as primary support for CPT/HCPCS procedure and ICD-9/ICD-10 diagnosis coding questions across Cambia, ensuring decision-making related to coding is consistent, clinically appropriate and thoroughly documented.

Applies coding expertise and judgment to assure medically appropriate and accurate claims adjudication.

Responds to customer inquiries regarding system functionality, modification and status of issue resolution.