What are the responsibilities and job description for the Payment Policy Manager position at Mass General Brigham Health Plan?
The Opportunity
The Payment Policy Manager is vital to the team and responsible for developing, implementing, and managing payment policies and strategies by analyzing regulatory changes and reimbursement models to optimize revenue and ensure compliance with federal, state, and payer-specific guidelines. This role works closely with clinical, financial, and revenue cycle teams to interpret payment policies and provide guidance on reimbursement practices that impact the organization's financial performance.
Essential Functions
*Evaluate current ClaimsXten/CCI configuration in collaboration with IT Configuration, the Data Steward, Claims staff and key stakeholders, ensuring that ClaimsXten configuration aligns with the approved business requirements and payment policies.
*Lead and contribute to business discussions re: coding, configuration and claim adjudication, drawing on claims experience, knowledge of regulatory requirements, industry standards re: coding and billing and payer benchmarking for ad hoc and system-wide decisions.
*Support the maintenance and enhancement of ClaimsXten/CCI information/documentation in Claim Editing Repository
*Research projects and the create written documentation as it relates to medical billing and coding rules and AllWays Health Partners' provider payment guidelines (PPGs).
*Regularly monitor changes in CMS coding regulations, state regulations and AMA guidelines and understand how these changes impact AllWays Health Partners' PPGs. Research and develop clear documentation of CMS's semi-annual update of code changes to support the Benefit & Coding Committee review process.
*Create reports and publish recommendations to the Provider Network Management leadership team on coding rules and provider payment policies to allow for informed operational and financial decisions, based on these results.
*Draft new and revised written provider payment guidelines based on decisions made by PNM leadership team, fee schedule methodology projects and decisions made by the Benefit & Coding Committee. Coordinate edit review of new and revised PPGs based on feedback received from Provider Payment Guideline Committee members.
*Coordinate the publishing of PPGs on AllWaysHealthPartners.org with Corporate Communications, within the timelines created by PNM service standards. Additionally, coordinate the distribution of finalized PPGs to impacted department with any required supporting documents.
*Participate in cross-functional teams and present research findings on medical coding and PPG issues to PNM Leadership team, the Provider Payment Guideline Committee and the Benefit & Coding Committee.
*Represent Reimbursement Strategy as a subject matter expert on corporate projects, committees or workgroups.
*Provide technical business summaries on claim editing topics in support of work required to develop and maintain business documentation
*Provide research and benchmarking on codes and claim edits represented by governmental and other regulatory agencies, as released quarterly; leading the code load process, including business requirements submission to IT Configuration
*Lead ClaimsXten and coding discussions on operational work and selected projects; working with colleagues from key areas including: IT Configuration, Claims, Compliance, Benefits Administration, Provider Payment Integrity and, Customer Service
*Monitor the accuracy of ClaimsXten documentation by monitoring and editing software as needed, reviewing online materials and by working with internal stakeholders as needed.
*Evaluate the ClaimsXten/CCI edits Library to identify and prioritize updates for QNXT, ClaimsXten, CCI and wizards.
*Lead ClaimsXten meetings and other meetings as assigned.
Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
Our promise as a people-first organization starts with our employees. AllWays Health Partners is committed to diversity, equity, and inclusion in our workforce, internal culture, and investments. As an equal opportunity employer, AllWays Health Partners recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives, and backgrounds.
Education
- Bachelor's Degree required
- Can this role consider or review experience in lieu of a degree? No
Experience
- At least 5-7 years of experience in payment policy management, managed care, reimbursement strategy, or healthcare finance required
- At least 1-2 years of experience in leadership or supervisory role
Skills for Success
- Ability to prioritize work and operate under tight deadlines.
- Strong aptitude for technology-based solutions.
- Demonstrated experience in policy development, contract management, and reimbursement strategy.
- Excellent analytical, communication, negotiation, and leadership skills.
Working Model Requirements
M-F Eastern Business Hours required
Onsite meetings will be planned ahead quarterly and are preferred, not required
Remote employee must work from a stable, secure, and compliant workstation in a quiet environment. Teams video is required and must be accessed using MGB-provided equipment. Interview process will also require Teams Video access.
Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
Our promise as a people-first organization starts with our employees. AllWays Health Partners is committed to diversity, equity, and inclusion in our workforce, internal culture, and investments. As an equal opportunity employer, AllWays Health Partners recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives, and backgrounds.