Claims Policy Analyst

This is a fully remote position, open to applicants in Missouri.

📋 Description

• Assess and interpret Payment Integrity policies, along with federal and state regulations and contract modifications, to ensure compliant and precise claims adjudication.

• Examine regulations, payer contractual obligations, and revisions to the internal Payment Integrity program for their effects on Claims and Configuration Operations.

• Offer insights on potential operational impacts or risks arising from proposed modifications.

• Review federal and state regulatory updates and bulletins to determine their relevance to claims processing and necessary customizations.

• Decode contractual clauses for the accurate implementation of benefits, payments, and policy logic within claims workflows.

• Assess policy revisions for their operational viability and impact on the claims system, including aspects of configuration, testing, and subsequent workflows.

• Collaborate with Claims and Configuration Operations to confirm rule interpretations and ensure adjudication precision.

• Work alongside PI Leadership, Medical Affairs, vendor partners, Compliance, and Health Plans during the pre-implementation phase.

• Create policy summaries, decision documentation, and operational guidance.

• Assist in developing provider education materials when policy changes necessitate external communication.

• Carry out additional responsibilities as assigned.

⛳️ Requirements

• Must possess authorization to work in the U.S. without requiring employment-based visa sponsorship now or in the future.

• Experience with benefit configuration is preferred.

• A High School Diploma or GED equivalent is mandatory.

• A minimum of 3 years of experience in health insurance, claims operations, payment integrity, auditing, or a related field is required.

• Certification as a CCS-Certified Coding Specialist, RHIT - Registered Health Information Technician, CPC - Certified Professional Coder, or an equivalent certification is required.

• Adherence to all policies and standards is essential.

🏝️ Benefits

• Health insurance

• 401K plan

• Stock purchase plans

• Tuition reimbursement

• Paid time off plus holidays

• Flexible work arrangements, including remote, hybrid, field, or office work schedules

• Competitive compensation

• Additional forms of incentives may be included in total compensation.