Behavioral Health Payment Policy Manager

WellSense Health Plan is a nonprofit health insurance company serving members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, no matter their circumstances.

Apply now (https://jobs.silkroad.com/BMCHP/Careers/Apply/MultiForm/294297)

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

The Behavioral Health Payment Policy Manager is responsible for managing and overseeing the development of payment policies to align with the organization’s Behavioral Health strategy and contractual/compliance requirements posed by regulatory oversight agencies, including CMS, MassHealth, NH Medicaid, and the DOI. This individual will collaborate with internal departments in creating and maintaining a cohesive set of policies to ensure payment alignment between policies, processes, systems, and encounter data.

Our Investment in You:

• Full-time remote work

• Competitive salaries

• Excellent benefits

Key Functions/Responsibilities:

· Develops and maintains organization Behavioral Health payment policies, and works collaboratively with the Payment Systems team to build system requirements to ensure consistency with adjudication systems.

· Develops and implements policy research and analysis strategies.

· Continually assesses and evaluates payment policy compliance with CMS, HIPAA, industry standards, plan policies, and regulatory requirements.

· Assesses regulatory changes to determine the scope and impact on payment operations and coordinates to implement changes as necessary.

· Collaborates with cross-functional business and IT partners to implement recommended policy changes.

· Maintains comprehensive understanding of and adherence to relevant policies, procedures, and regulations while staying abreast of changes and/or updates in regulations or competitive market space.

· Participates in various work groups and committees to support Behavioral Health payment policies and provides input into processes and workflows reliant on payment policy outcomes.

· Develops 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 Payment Policy Committee; and subsequently ensure successful completion of change.

· Serves as the organization’s subject matter expert regarding Medicare and Medicaid Behavioral Health payment policies.

· Researches, identifies and proposes opportunities for performance improvement initiatives to improve claim adjudication and payment accuracy.

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

Qualifications:

Education:

• Bachelor’s Degree in a related field or the equivalent combination of training and experience

Education Preferred/Desirable:

• AHIMA or other nationally recognized Coding Certification

Experience:

· 6 or more years experience in a fast paced, managed healthcare environment is required.

· 6 or more years direct work in claims processing, payment policy, or contracting.

· Extensive background of facility or professional claim billing and coding principles.

· Extensive knowledge of claim editing standards (NCCI, etc.).

· Experience working with industry standard methods of payment including DRG, EAPG, APC, etc.

· Experience working with Medicare, Medicaid or commercial Behavioral Health billing, coding, or payment rules and regulatory requirements.

· Experience researching and interpreting Medicare, Medicaid, or other governmental Behavioral Health regulations.

Experience Preferred/Desirable:

· Optum Claim Editing System (CES), Data Driven Rules

· Optum Prospective Payment Systems

· Cognizant Facets claim adjudication system

· Experience with HIPAA transaction and 837 standards

Competencies, Skills, and Attributes:

• Demonstrated proficiency in coding and knowledge of the requirements of industry standards such

as Medicare and/or Medicaid regulations.

• Strong understanding of HIPAA Guidelines.

• Good communication skills, both oral and written, ability to interact well with others at all levels,

strong organizational skills, strong customer service skills and orientation.

• Expertise utilizing Microsoft Office products.

• Effective collaborative and proven process improvement skills.

• A strong working knowledge of Microsoft Office products.

• Excellent analytic and problem solving skills and ability to manage multiple projects and priorities.

• Ability to organize, meet deadlines, and multi-task.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

Apply now (https://jobs.silkroad.com/BMCHP/Careers/Apply/MultiForm/294297)

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