Resp & Qualifications

PURPOSE:
The Payment Policy Analyst will research, develop, and coordinate the distribution and maintenance of payment policies in support of corporate payment methodologies, provider contracts, claims adjudication rules, and applicable regulatory and industry standards. This role applies analytical skills and subject matter knowledge to evaluate the impact of payment policies and ensure accurate implementation. We are looking for experienced professionals to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities.

ESSENTIAL FUNCTIONS:

• Performs in-depth research on topics identified as actual or potential payment policies. Evaluates CMS guidance, industry references, peer health plan policies, coding conventions, and other authoritative sources to determine appropriateness for policy development. Assesses and communicates the operational, financial, and provider impact of payment policy decisions.
• Writes evidence-based payment policies and operating procedures related to reimbursement methodologies, coding and billing rules, legislative and regulatory mandates, contractual provisions, and corporate payment philosophy to ensure consistent application across all lines of business.
• Maintains the Payment Policy Reference Manual (PPRM), including resource files and supporting documentation. Ensures dissemination of payment policies and procedures to implementation teams (e.g., claims, configuration, provider operations) and other appropriate departments. Ensures maintenance and accuracy of online policy content, responds to business inquiries, and provides written clarification of existing and emerging payment policies and trends.

QUALIFICATIONS:

Education Level: Bachelor's Degree in Health Administration, Business, Finance, Nursing or related discipline OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Licenses/Certifications Upon Hire Required:

• Certified Coder (CCS or CPC)-AHIMA or AAPC AAPC Certified Professional Coder (CPC) or AHIMA Certified Coding Specialist (CCS).

Experience: 3 years experience in payment policy, reimbursement policy, claims configuration, billing rules, and/or coding guidelines in a health care or health plan setting.

Preferred Qualifications:

• Advanced knowledge of CPT, HCPCS, ICD-10-CM/PCS coding systems and claims reimbursement rules.
• Experience in technical writing, reimbursement methodologies, health economics or statistics.

Knowledge, Skills and Abilities (KSAs)

• Ability to analyze complex information, make sound decisions, and resolve policy-related issues.
• Demonstrated ability to work collaboratively across operational and technical teams.
• Strong written and verbal communication skills, including ability to present to internal stakeholders at all levels.
• Use of Microsoft Office applications (Excel, PowerPoint, Word).
• Working knowledge of medical insurance and managed care principles.
• Knowledge of fee schedules, payment methodologies, bundling logic, modifiers, and places of service.
• Knowledge of standardized processes for evaluating payment support operations and claims adjudication practices.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range: $58,320 - $115,830

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

Health Services

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

#LI-SS1