The Medicare Coverage Analyst (MCA) is responsible for reviewing clinical research protocols, Informed Consent Forms, Clinical Trial Agreements, and other relevant study-related documents to create a coverage analysis/billing guide. The coverage analysis indicates which medical procedures/services maybe 'Routine Cost' and billable to patient insurance and which should be billed to the study sponsor.
The Medicare Coverage Analyst determines whether proposed clinical research studies are a Qualifying Clinical Trial as defined by the Medicare Clinical Trial Policy (NCD 310.1) and designates medical procedures/services based on relevant regulations and determinations.
The Senior Medicare Coverage Analyst applies subject matter expertise to complex protocols and mentors/trains junior team member.
- Mentors and trains junior MCA staff, provides second-level review of junior staff determinations
- Creates coverage analysis grids for complex protocols
- Serves as National and Local Coverage Determination (LCD and NCD) subject matter expert - disseminating changes to Medicare payor policy to other members of the MCA team
- Triages and prioritizes coverage analysis workflow based on institutional need across disease centers - communicates MCA execution timelines to study teams and external stakeholders
- Serves as the primary point of contact for urgent protocol amendments with budgetary and MCA impact, prioritizes and executes in narrow timelines
- Independently interfaces with sponsors and sponsor representatives to resolve discrepancies in specific protocol assessments
- Interfaces with study team and principal investigators prior to protocol submission to assist with MCA determinations/study design
KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED: - Understanding of research activity in an academic medical center
- Knowledge of billing compliance and Medicare regulations/policy, applicable federal, state, and local laws, rules, regulations and policies and institutional policies and standard operating procedures
- Knowledge of clinical research budgeting and the clinical trial life cycle: study start-up through study closure
- Knowledge of clinical trials management system (CTMS)
- Ability to independently facilitate outreach/communication between study team and sponsor
MINIMUM JOB QUALIFICATIONS:- The position requires a bachelor's degree or RN credential
- 5 years of experience in Medicare coverage analysis.
- Candidates should have experience with research activities in an academic medical center
- Working with clinical trials management systems (CTMS).
- CPT/DRG coding experience is preferred.
SUPERVISORY RESPONSIBILITIES: None
PATIENT CONTACT: None
The hiring range is based on market pay structures, with individual salaries determined by factors such as business needs, market conditions, internal equity, and based on the candidate's relevant experience, skills and qualifications.
For union positions, the pay range is determined by the Collective Bargaining Agreement (CBA).
$77,500.00 - $90,400.00
