Job Family:Strategy & Transformation Consulting
Travel Required:Up to 25%
Clearance Required:Ability to Obtain Public Trust
We are looking for a Healthcare Claims Payment Policy expert to draft, standardize, implement, and maintain payment policies that improve payment accuracy, cost control, provider experience, and compliance in a large payer environment. In this role, you will help shape how reimbursement policies are researched, written, operationalized, and communicated across clinical, operational, finance, legal, analytics, and implementation stakeholders. You will translate reimbursement research, claims data, stakeholder input, and policy decisions into clear, operationally usable guidance that supports consistent claims adjudication and stakeholder understanding. The ideal candidate brings strong payer and provider reimbursement policy experience, including knowledge of Medicare, Medicaid, TRICARE, commercial payer policy, provider billing standards, claims coding, modifiers, fee schedules, and reimbursement impact analysis.
What You Will Do: - Support the payment policy workstream. Set priorities, manage the policy portfolio, align stakeholders, and drive timely decisions that support accurate and consistent reimbursement.
- Draft and standardize payment policies. Write, update, and maintain clear payment policies, reimbursement guidance, FAQs, briefings, and implementation materials.
- Translate policy into operational requirements. Convert reimbursement policy, payer guidance, coding requirements, and stakeholder decisions into claims rules, edits, bundles, business requirements, payment controls, fee schedules, and operational decision logic.
- Support implementation and stakeholder adoption. Coordinate readiness, communications, testing support, reimbursement logic clarification, issue resolution, and stakeholder materials so policies are understood and applied consistently.
- Monitor reimbursement policy changes. Track federal, state, and commercial payer updates, coding changes, fee schedule changes, and provider billing guidance to keep policies current.
- Analyze reimbursement and claims impact. Define data needs, review claims and reimbursement data, assess payment impacts, and use findings to inform policy decisions, implementation planning, and stakeholder discussions.
What You Will Need: - 5+ years in payment policy, reimbursement policy, payment integrity, claims, revenue cycle, fee schedule development, or healthcare reimbursement.
- Experience drafting, standardizing, implementing, and maintaining payment policies, reimbursement guidance, provider billing guidance, and stakeholder communications.
- Knowledge of Medicare, Medicaid, TRICARE, commercial payer reimbursement policy, provider billing standards, fee schedules, claims adjudication rules, and healthcare claims coding concepts including CPT, HCPCS, ICD, revenue codes, DRGs, modifiers, bundled payments, unlisted codes, non-reimbursable codes, and claims edits.
- Ability to translate reimbursement policy and payer guidance into claims rules, edits, bundles, business requirements, payment controls, operational decision logic, and defensible payment integrity approaches.
- Ability to translate policy questions into data requests, interpret claims and reimbursement data, and clearly explain operational and payment impact to technical and non-technical stakeholders.
What Would Be Nice To Have: - Experience working in a large federal health, payer, or provider environment with complex reimbursement policies, multiple stakeholders, and cross-functional implementation partners.
- Experience supporting third-party administrator or claims operations implementation, including translating policy into business requirements, clarifying reimbursement logic, supporting testing, resolving operational questions, and tracking implementation issues.
- Experience conducting claims, reimbursement, cost, or payment impact analyses using Excel, Power BI, Tableau, SQL, or similar tools.
- Experience leading a team or workstream, including setting priorities, assigning work, reviewing deliverables, coordinating subject matter experts, tracking deadlines, and communicating status, risks, and decisions to leadership.
What We Offer:Guidehouse offers a comprehensive, total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace.
Benefits include:
- 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
- Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
- Short-Term & Long-Term Disability
- Student Loan PayDown
- Tuition Reimbursement, Personal Development & Learning Opportunities
- Skills Development & Certifications
- Employee Referral Program
- Corporate Sponsored Events & Community Outreach
- Emergency Back-Up Childcare Program
- Mobility Stipend
