Why This Role is Important to Us:

Position Summary:

This is an individual contributor role. Working under the direction of the Sr. Director, TPA Management and Claims Compliance, Medical/BH Reimbursement Policy Manager will have overall responsibility for CCA's reimbursement policies for ICO and SCO programs. As a subject matter expert, this position will be responsible for overseeing Medical and Behavioral Health reimbursement policies for statewide impact. The Policy Manager is responsible for managing cross-departmental implementation of changes to payment and billing policies as necessary due to regulatory changes, contractual changes, or because of data findings. The Policy Manager will collaborate with internal departments to define requirements and to document those requirements sufficiently to ensure accurate implementation of payment rules within the Plan's claims adjudication system, including the claim editing systems (CES and Zelis).The Policy Manager will also review current payment policies and compare them to those used by competitor, state regulatory agencies, and CMS to evaluate and recommend changes, and upon approval incorporate such changes into materials. As directed by the department manager, he/she will project manage regulatory changes that impact payment methods, billing/coding or rates, and help drive analytics to support decision making.

Supervision Exercised:

• No, this position does not have direct reports.

What You'll Be Doing:

Essential Duties & Responsibilities:

• Develops and maintains corporate reimbursement policies, and works collaboratively with the Claims Coding Analyst to ensure consistency with the Plan's claims processing system(s)

• Monitors DHHS, EOHHS, and CMS websites, listservs and other sources to identify existing payment practice and upcoming changes

• Determine the scope and impact of the change on Plan operations and seek to implement changes as necessary

• Responsible to run various work groups and committees to support reimbursement policies and provides input into processes and workflows reliant on reimbursement policy outcomes

• Serve as the department's project manager for: (1) regulatory information such as proposed and final Medicare and/or Medicaid payment regulations, Medicare Manual updates, DHHS and EOHHS fee schedules; and (2) regulatory issues

• Determine the scope and impact of the information/issues and take appropriate action

• Collaborate with Public Partnerships, Contracting, Medical Economics, Provider Relations, Benefit Administration, Business Configuration, and Provider Audit/OPL to determine the impact of implementing recommended policy changes

• Develop project plans including: setting timelines and deliverables; determining resource requirements; documents decisions; draft communication plan; information-sharing with appropriate staff and seek approval from the Reimbursement Policy Committee; and subsequently ensure successful completion of change

• Serve as the company's research specialist regarding Medicare and Medicaid payment policies

• Serves on the Operational Excellence Committee to ensure a consistent understanding of operational changes as they relate to payment policies and their downstream impact within the Claims department

• Submits recommendations to the Payment Policy Committee and supports Committee efforts through subgroups and individually as needed

• Collaborate with stakeholder departments to develop and maintain a database to serve a centralized location to store payment methodology information

• Research, identify and propose opportunities for medical cost savings, improve claim auto adjudication rate and payment accuracy

• Write reimbursement policies for a variety of audiences, providing Medicare/Medicaid business requirements for payment system changes

• Interpreting and implementing complex Medicare and Medicaid regulations specific to ICO/SCO programs

Working Conditions:

• Standard office conditions.

What We're Looking For:

Required Education (must have):

• Bachelor's Degree in health care or health care policy development

Desired Education (nice to have):

• AHIMA or other nationally recognized Coding Certification preferred

• Master's Degree or graduate work in a related field preferred

• Coding Certification for Payers 9CPC-P) preferred

Required Experience (must have):

• 7 or more years' experience in a fast paced, managed healthcare environment is required

• 7 or more years direct work in claims processing, payment policy, or contracting

• Extensive background of ICD-9 and CPT coding principles

• Extensive knowledge of medical claim editing (NCCI, etc.)

• Experience working with industry standard methods of payment including DRG, APC, RVU, etc.

• Experience working with Medicaid, Medicare and commercial coding rules/ regulatory requirements

• 7+ years progressive experience in medical claims adjudication, clinical coding reviews for claims, settlement, claims auditing and/or utilization review required

• Proven ability to apply quantitative and/or qualitative research and data analysis techniques to improve operational processes.

• Must understand trend information and be familiar with claim coding practices and industry issues in Medicare payment methodologies.

• Advance level experience with Excel and other data systems

• Excellent collaboration and communication skills with the ability to partner effectively across the organization and with external partners

Desired Experience (nice to have):

• Experience with ancillary, long term care, and community-based providers preferred

Required Knowledge, Skills & Abilities (must have):

• Excellent understanding of health care industry and market assessment

• High organizational and time management skills

• Strong analytical and problem-solving skills

• Excellent verbal and written communication skills

• Exceptional team player with a strong ability to contribute positively to a team environment under minimal supervision

• Strong health policy analytical skills and familiarity with Medicare and MassHealth policies.

• Knowledge and experience of health care reimbursement, public health care programs and reimbursement methodologies (Medicaid and Medicare)

• Applies subject matter knowledge; requires capacity to understand specific needs or requirements to apply skills/knowledge

• Ability to plan, organize, and manage own work; set priorities and measure performance against established benchmarks

• Comfort working with and communicating new policies

• Ability to communicate and work effectively at multiple levels within the company

• Customer service orientation: positive outlook, self-motivated and able to motivate others

• Strong work ethic: able to solve problems and overcome challenges

• Actively participates in the evaluation of own performance.

Required Language (must have):

• English

Desired Knowledge, Skills, Abilities & Language (nice to have):

• Working knowledge of health care reimbursement, claims, and data systems preferred

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.