Payment Cycle Analyst II

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

📋 Description

• Establish clinical and payment policy requirements for the setup of clinical editing systems.

• Investigate potential reimbursement policy claim edits, which includes sourcing support, conducting data analysis, ensuring regulatory consistency, and assessing network impacts.

• Analyze claim results to pinpoint errors and inconsistencies related to clinical edits, coding, payment policies, fee schedules, and rates.

• Perform both systemic and targeted analyses to uncover reimbursement errors and their underlying causes.

• Prepare, review, and secure approval for clinical and payment policy analyses and documentation prior to implementation.

• Contribute to User Acceptance Testing (UAT) and carry out post-production validation.

• Produce written and verbal communications that summarize findings and provide fact-based recommendations for providers, provider associations, and Health Partner Managers.

• Log open issues, configuration designs, and final resolutions.

• Examine and interpret regulatory items and deliver necessary updates.

• Assist with system change policy initiatives, deliver updates during payment policy meetings, and present to stakeholders.

• Oversee configuration and claims Standard Operating Procedures (SOPs) to ensure payment accuracy.

• Aid in the development of policies and procedures for claims processing, coordination of benefits (COB), appeals, and adjustments.

• Ensure payment policies and decisions are documented and support provider education initiatives with the Health Partner team.

• Carry out additional responsibilities as needed.

⛳️ Requirements

• A Bachelor’s degree or equivalent relevant work experience is mandatory.

• A minimum of three (3) years of experience in a health plan setting is required, or equivalent experience with provider coding and claim payment policies.

• Experience with clinical editing software is preferred.

• Advanced proficiency in Microsoft Office Suite, including Word, Excel, Access, and Visio.

• Strong computer skills and familiarity with Facets.

• A solid understanding of claims operations, configuration, and clinical editing in managed care.

• Comprehensive knowledge of ICD-9/ICD-10, CPT, HCPC, REV, DRG, and RUG code sets.

• Knowledgeable in HIPAA Transaction Codes.

• Proficient in data analysis and trending.

• Exceptional written and verbal communication skills.

• Strong understanding of claims processing edits and logic.

• Familiarity with CMS guidelines, HIPAA, and the Affordable Care Act.

• Experience with reporting packages and generating system reports.

• Certification as a Medical Coder is preferred.

• Ability to work autonomously as well as collaboratively within a team environment.

• Occasional travel of up to 10% may be necessary.

🏝️ Benefits

• A bonus linked to both company and individual performance may be available.

• A comprehensive total rewards package.

• Opportunities for occasional travel to meetings, training sessions, and conferences.