Payment Policy Manager
Payment Policy Manager
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1 Vacancy
Job Description
Mass General Brigham relies on a wide range of professionals including doctors nurses business people tech experts researchers and systems analysts to advance our mission. As a notforprofit we support patient care research teaching and community service striving to provide exceptional care. We believe that highperforming teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.
The ideal candidate is a CPC with strong writing skills since this role is writing providerfacing policies and experience with claims editing software (like ClaimsXten).
Job Summary
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 payerspecific 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 organizations financial performance.Does this position require Patient Care
No
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 systemwide 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 CMSs semiannual 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 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 crossfunctional 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.
Qualifications
Education
Bachelors Degree required
Can this role accept experience in lieu of a degree
No
Experience
- At least 57 years of experience in payment policy management managed care reimbursement strategy or healthcare finance required
- At least 12 years of experience in leadership or supervisory role
Knowledge Skills and Abilities
- Ability to prioritize work and operate under tight deadlines.
- Strong aptitude for technologybased solutions.
- Demonstrated experience in policy development contract management and reimbursement strategy.
- Excellent analytical communication negotiation and leadership skills.
Additional Job Details (if applicable)
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
EEO Statement:
Mass General Brigham Competency Framework
At Mass General Brigham our competency framework defines what effective leadership looks like by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half PeopleFocused half PerformanceFocused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance make hiring decisions identify development needs mobilize employees across our system and establish a strong talent pipeline.
Required Experience:
Manager
Employment Type
Full-Time
