Healthcare Claims Payment Policy Managing Consultant

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

📋 Description

• Assist the payment policy workstream by establishing priorities, managing the policy portfolio, aligning stakeholders, and facilitating timely reimbursement decisions.

• Create, revise, standardize, and uphold payment policies, reimbursement guidelines, FAQs, briefings, and implementation resources.

• Convert reimbursement policies, payer guidelines, coding requirements, and stakeholder decisions into claims rules, edits, bundles, business requirements, payment controls, fee schedules, and operational decision-making logic.

• Oversee implementation readiness, communication efforts, testing support, clarification of reimbursement logic, issue resolution, and stakeholder resources.

• Track updates from federal, state, and commercial payers, including coding modifications, fee schedule alterations, and provider billing guidance.

• Identify data requirements, examine claims and reimbursement data, evaluate payment impacts, and utilize insights to inform policy decisions and implementation strategies.

• Articulate operational and payment implications to both technical and non-technical stakeholders.

⛳️ Requirements

• 5+ years of experience in payment policy, reimbursement policy, payment integrity, claims management, revenue cycle, fee schedule development, or healthcare reimbursement.

• Proven experience in drafting, standardizing, implementing, and maintaining payment policies, reimbursement guidance, provider billing guidance, and communications with stakeholders.

• Familiarity with Medicare, Medicaid, TRICARE, commercial payer reimbursement policies, provider billing standards, fee schedules, claims adjudication rules, and healthcare claims coding concepts.

• Knowledge of CPT, HCPCS, ICD, revenue codes, DRGs, modifiers, bundled payments, unlisted codes, non-reimbursable codes, and claims edits.

• Capability to translate reimbursement policies and payer guidance into claims rules, edits, bundles, business requirements, payment controls, operational decision-making logic, and defensible payment integrity strategies.

• Skilled in converting policy inquiries into data requests, interpreting claims and reimbursement data, and communicating operational and payment impacts to both technical and non-technical audiences.

• Must be able to obtain Public Trust clearance.

• Willingness to travel up to 25%.

• Preference will be given to candidates residing in the Washington, DC metro area.

🏝️ Benefits

• Medical, Rx, Dental & Vision Insurance.

• Personal and Family Sick Time & Company Paid Holidays.

• Position may be eligible for a discretionary variable incentive bonus.

• Parental Leave and Adoption Assistance.

• 401(k) Retirement Plan.

• Basic Life & Supplemental Life Insurance.

• Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts.

• Short-Term & Long-Term Disability Insurance.

• Student Loan PayDown Program.

• Tuition Reimbursement, Personal Development & Learning Opportunities.

• Skills Development & Certifications.

• Employee Referral Program.

• Corporate Sponsored Events & Community Outreach.

• Emergency Back-Up Childcare Program.

• Mobility Stipend.

• Flexible benefits package.