Payment Policy Analyst

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Job description

JOB SUMMARY:

Develop and evaluate the effectiveness of company medical, administrative, and reimbursement policies. Research and develop new policies as well as changes to existing policies on a regular basis. Perform industry evaluations/benchmarking of BCBSRI policies to industry standards. Perform limited evaluation of medical documentation submitted to ensure compliance with BCBSRI's payment policies. Work with other internal business and clinical associates and medical directors in the development and approval of both new and updates to existing policies. Ensure internal training materials and external provider documentation is consistent with company policies and state and federal guidelines and/or accreditation requirements.

ESSENTIAL JOB FUNCTIONS:

• Evaluate effectiveness of company medical, administrative, and reimbursement policies; serve as internal and external contact for inquiries related to policies. Work closely with medical staff to review existing policies and develop recommendations for new policies.
• Ensure adherence to corporate timelines and quality standards for creation of new and reviews of existing policies, while adhering to applicable state and federal guidelines, accreditation agencies (e.g. NCQA, as well as Centers for Medicare and Medicaid Services (CMS) requirements and guidance.
• Direct internal areas in the development and implementation of policies. Provide education to staff regarding policy administration.
• Participate in department initiatives and projects. Serve as department representative and participate on projects related to company medical, administrative, and reimbursement policies.
• Maintain provider manuals and internal training materials; ensure materials are consistent with policies and state and federal guidelines.
• Establish criteria for the financial impact analysis of policies; collaborate with internal areas to obtain financial data. Participate in the testing and creation of business requirements for the system request process. Monitor status reports to ensure timely implementation and communication (internal and external) of system changes.
• Perform other duties as assigned.

QUALIFICATIONS:

Minimum Education and Experience:

• Bachelor's Degree in Nursing, Business Administration, Healthcare Services or related field, or an equivalent combination of education and experience
• Three to five years of experience in medical policy review, quality management or an analytical discipline
• Certified Professional Coder (CPC) Certification
• Proficiency with Microsoft Suite of products (i.e., Word, Excel, PPT, etc.)

Preferred Education, Additional Qualifications and Experience:

• Proficiency in web-based searching and CMS website navigation
• Contract knowledge and knowledge of provider risk arrangements
• Knowledge of managed benefits strategies, utilization review techniques, healthcare financing and delivery

Required Knowledge, Skills, and/or Abilities:

• Medical policy and benefit knowledge
• Knowledge of medical terminology and claims payment policies including applicable coding methodology
• Advanced analytical skills, with the ability to interpret and synthesize complex data sets
• Good business acumen and political savvy
• Knowledge of business process improvement techniques and strategies
• Ability to work independently or as an active member of a team
• Accurate and precise attention to detail
• Ability to multitask, prioritize, and manage time efficiently
• Excellent verbal and written communications skills
• Negotiation skills
• Presentation skills
• Decision-making skills
• Good problem-solving skills
• Ability to interface with employees at all levels
• Ability to effectively navigate ambiguous situations with limited direction
• Excellent organizational skills and ability to successfully prioritize multiple tasks
• Ability to handle multiple priorities/projects