Policy & Implementation Analyst

Telecommute Option - Must reside in ID, OR, UT or WA

WHO WE NEED

The Policy and Implementation Analyst uses Medical coding knowledge and experience and evaluates, recommends and implements clinical editing solutions to assure accurate outcomes consistent with medical and reimbursement policy and financial targets.

This role develops and executes implementation plans to include system updates, business process changes and timely communication.

The position develops, maintains and publishes reimbursement policy.

Clinical knowledge (Understands clinical reviews)

Understanding of claims , billing and coding

Understanding of Medical and reimbursement policies

CPC Certified or willing to get CPC Certified as condition to position.

Policy and Implementation Analyst would have a Bachelor’s degree in Business Administration or a related field and 3 years of experience in a healthcare related environment utilizing analytical skills or an equivalent combination of education and experience.

Required Licenses, Certifications, Registration, Etc.

Current licensure or professional certification relevant to the work (coding certification) is preferred.

YOUR ROLE :

Facilitates development, understanding and documentation of business requirements related to policy implementation and clinical editing.

Performs analysis in the design and implementation plans to support new and revised medical and reimbursement policies.

Responsible for maintaining online documentation for accurate and uniform administration of medical and reimbursement policy.

Coordinates the implementation of new and revised online reference materials and technical documentation.

Communicates policy and edit decisions to internal and external customers in a clear and concise manner.

Creates configuration instructions for clinical edits and preauthorization flags to support medical and reimbursement policy and ensure accurate implementation in multiple claims editing systems.

Tracks, coordinates and oversees medical and reimbursement policy and related clinical edit and coding issues through the implementation process.

Collaborates with other departments to coordinate system implementations, process changes, investigate claims adjudication and member or provider inquiries.

Collaborates with medical directors to ensure clinically appropriate polices and edits.

Identifies data necessary for project, analyzes and transforms data into practical information for communication to stakeholders to drive and support decisions.

Designs and develops testing plans that ensure all key areas are tested sufficiently for successful production results.

Develops reimbursement policies and coordinates reimbursement policy development to include identification of issues, policy research and development, policy approval, policy implementation and policy documentation and education.

WHAT YOU BRING :

Ability to communicate effectively, verbally and in writing.

Understanding of claims processing to evaluate implementation needs

Demonstrated analytical ability to identify problems, develop solutions and implement a chosen course of action.

Ability to present issues, lead and / or participate in discussions and develop conclusions with internal and external medical professionals and other experts.

General computer skills (including use of Microsoft Office, Outlook and internet search).

Familiarity with health care documentation systems.

Proven ability to perform and manage analytical tasks / projects with the ability to work independently.

Demonstrated knowledge of the following : CMS reimbursement and medical policies; Medicare products; Procedural and diagnostic coding;

and the national Resource Based Relative Value Schedule.

Serves as primary support for CPT / HCPCS procedure and ICD-9 / ICD-10 diagnosis coding questions across Cambia, ensuring decision-making related to coding is consistent, clinically appropriate and thoroughly documented.

Applies coding expertise and judgment to assure medically appropriate and accurate claims adjudication.

Responds to customer inquiries regarding system functionality, modification and status of issue resolution.

The expected target hiring range for this position is $66.7k $90.2k depending on skills, experience, education, and training;

relevant licensure / certifications; performance history; and work location. The bonus target for this position is 10% .

The current full salary range for this position is $62.5k Low Range / 78.5k MRP / $102.5k High Range.

Base pay is just part of the compensation package at Cambia that is supplemented with an exceptional 401(k) match, bonus opportunity and other benefits.

In keeping with our Cause and vision, we offer comprehensive well-being programs and benefits, which we periodically update to stay current. Some highlights :

medical, dental, and vision coverage for employees and their eligible family members

annual employer contribution to a health savings account ($1,200 or $2,500 depending on medical coverage, prorated based on hire date)

paid time off varying by role and tenure in addition to 10 company holidays

up to a 6% company match on employee 401k contributions, with a potential discretionary contribution based on company performance (no vesting period)

up to 12 weeks of paid parental time off (eligible day one of employment if within first 12 months following birth or adoption)

one-time furniture and equipment allowance for employees working from home

up to $225 in Amazon gift cards for participating in various well-being activities. for a complete list see our page.

We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace.

All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law.

A background check is required.

If you need accommodation for any part of the application process because of a medical condition or disability, please email .

Information about how Cambia Health Solutions collects, uses, and discloses information is available in our . As a health care company, we are committed to the health of our communities and employees during the COVID-19 pandemic.

Last updated : 2024-04-30