Benefit and Reimbursement Policy Program Manager
Benefit and Reimbursement Policy Program Manager
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Job Description
Join Martins Point Health Care - an innovative not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force ofpeople caring for people Martins Point employees are on amission to transform our health care system while creating a healthier community. Martins Point employees enjoy an organizational culture of trust and respect where our values - taking care of ourselves and others continuous learning helping each other and having fun - are brought to life every day. Join us and find out for yourself why Martins Point has been certified as a Great Place to Work since 2015.
Position Summary
Job Description
The Benefit and Reimbursement Policy Program Manager leads Health Plan and shared service teams to execute Health Plan Operations strategy and work streams including benefits and payment policy development review and implementation in core claims processing system and all applicable internal supporting systems. The Program Manager leads the above through analysis & research evaluation of regulatory requirements benchmarking against industry best practices integrating stakeholder priorities and aligning organizational policies with systems and operations. The Program Manager will serve as a key liaison across claims operations system configuration audit & recovery and compliance teams to manage reimbursement policy changes evaluate impacts and support accurate claims adjudication.
PRIMARY DUTIES AND RESPONSIBILITIES
- Serves as the operational lead for the development implementation and management of benefit and reimbursement policies across Medicare and USFHP lines of business.
- Analyzes current and proposed regulations to assess operational clinical and financial impacts; translate CMS DHA and vendor contract language into actionable internal changes and system requirements.
- Collaborates with finance clinical compliance and operational teams to ensure policies are financially sound regulatory appropriate and administratively feasible.
- Coordinates with Reporting/Analytics to evaluate the impact of benefit and code changes on systems members and financials; present findings to Claims leadership to inform business decisions.
- Monitors CMS/DHA updates (e.g. Final Rules NCDs LCDs) and lead timely updates to policies ensuring compliance with regulatory changes and internal strategy.
- Develops and maintain comprehensive documentation including policies procedures configuration tickets and workflows in alignment with audit and transparency standards.
- Oversees benefit configuration and ensure timely integration of new/revised codes into pricing and adjudication systems (e.g. QNXT).
- Ensures accurate implementation of benefits and reimbursement policies in core processing systems by partnering with the HPA team and other stakeholders.
- Monitors policy performance metrics and evaluate operational provider and member impacts to inform continuous improvement.
- Leads or participate in cross-functional workgroups and initiatives related to benefit optimization cost containment and reimbursement strategies.
- Applies project management principles to regulatory and policy implementation including task planning issue resolution and risk mitigation.
- Serves as subject matter expert and communicate policy changes and updates to internal stakeholders.
- Supports internal and external audits regulatory reporting and ensure alignment with industry best practices and compliance requirements.
- Establishes and maintain quality control mechanisms to ensure consistency and accuracy in policy and workflow execution.
- Utilizes all relevant tools databases and reference materials to inform policy development and decision-making.
POSITION QUALIFICATIONS
Education
- Bachelors degree or equivalent combination of education and relevant experience
Licensure/certification
- CPC or willingness to get one.
Experience
- 6 years of experience in health administration policy development and/or implementation overseeing projects in matrix environment
- Experience interpreting regulatory guidance and explaining related concepts in easy-to-understand way to various audiences
- Experience with QNXT Processing System required
Knowledge
- Strong knowledge of medical billing CPT/HCPS ICD-10 coding and payer regulations
- Broad knowledge of managed care and health plan functions
- Medicare Advantage and USFHP/TRICARE knowledge and experience highly preferred
- Detailed understanding of MPHC claim types workflows and processes preferred.
Skills
- Competence with computers and business applications; QNXT Claims Adjudication Platform; Microsoft Excel Microsoft Word Microsoft Outlook
Abilities
- Exhibits flexibility to adapt feedback coaching and auditing approach to meet evolving business and staff requirements and assume other duties as needed.
- Excellent organizational skills required.
- Capacity to work independently and manage multiple priorities required.
- Superior written and oral communication skills required.
- Excellent organizational skills required.
- Demonstrated project management skills overseeing complex projects in matrix environment.
- Excellent communication and presentation skills oral and written.
- Strong organizational skills including the ability to work independently and prioritize work.
- Strong ability to build consensus around complex business and technical decisions
- Demonstrates an understanding of and alignment with Martins Point Values.
- Oversee multi-disciplinary workgroups in achieving team objectives without direct authority.
- Strong attention to detail and the ability to multitask.
- Ability to review interpret and present information to Health Plan Leadership and external partners.
- Ability to lead change
This position is not eligible for immigration sponsorship.
We are an equal opportunity/affirmative action employer.
Do you have a question about careers at Martins Point Health Care Contact us at:
Required Experience:
Manager
Employment Type
Full-Time
