Other Service Line Geospatial Manager MAP GSMNGR

Consultant - Medical Coding and Reimbursement Policies
Max Vendor Rate: $110
Location: Remote. Preferred time zone - EST

Role Clarity (For Suppliers):
We need candidates with experience in payer industry and not the provider.
Hands on analytics policy intelligence
Independent ownership and recommendations
Industry trend analysis expected
Not a pure people management role
Not limited to risk adjustment
Not junior or support only

Top Skills:
1. Medical Coding
2. Reimbursement Policies and CMS guidelines
3. Industry trends on the policies and coding guidelines

Role Summary
The Payment Integrity Analyst Post Payment Audits Claims Analytics & Reimbursement Policy Strategy is responsible for independently analyzing medical claims trends post payment audit outcomes and industry wide provider reimbursement policy trends to identify payment integrity risks and improvement opportunities.
This role combines hands on claims analytics with external market intelligence requiring the ability to evaluate evolving reimbursement practices across the industry and recommend applicable policies that improve payment accuracy compliance and financial integrity.
Key Responsibilities
1. Claims Trend & Post Payment Audit Analysis
Analyze large volumes of paid medical claims data to identify adverse trends recurring payment issues and financial leakage.
Perform root cause analysis on claims impacted by clinical edits coding discrepancies reimbursement policy gaps and configuration issues.
Review and validate post payment audit findings from vendors (coding audits DRG audits COB audits itemized bill reviews).
Recommend appropriate actions including claim recycling adjustments recoupments or audit reversals.
2. Clinical Editing & Reimbursement Policy Application
Interpret and apply reimbursement policies clinical guidelines and payment integrity rules (CMS and payer specific).
Analyze claims impacted by clinical edits (NCCI MUE LCD/NCD DRG/APR DRG E&M leveling modifiers).
Identify policy ambiguities or gaps contributing to payment inaccuracies and recommend remediation.
3. Industry Trends Provider Reimbursement Policies (NEW / KEY EXPECTATION)
Research and monitor industry trends in provider reimbursement policies across:
o CMS Medicare & Medicaid
o Commercial payers
o Blue plans and peer payer organizations
Analyze emerging reimbursement methodologies policy language changes and enforcement patterns impacting provider billing and payment integrity.
Benchmark internal reimbursement practices against industry standards and competitor policies.
Identify new payment integrity opportunities driven by:
o Evolving clinical practices
o Regulatory updates
o Provider billing behavior trends
4. Policy Recommendation & Advisory Role (NEW)
Recommend new or updated reimbursement policies based on:
o Industry trends
o Audit findings
o Claims analytics insights
Provide data backed justification for policy adoption refinement or retirement.
Advise stakeholders on policy applicability financial impact compliance risk and operational feasibility.
Support policy governance discussions by translating complex findings into clear executive ready recommendations.
5. Payment Integrity Strategy & Prevention
Support payment integrity initiatives by identifying preventive controls to reduce post pay recoveries.
Quantify financial impact savings opportunities and risk exposure tied to policy and audit findings.
Collaborate with configuration operations and IT teams to implement system edits rule changes or process improvements that prevent recurrence.
6. Reporting & Stakeholder Communication
Develop executive level dashboards summaries and presentations highlighting:
o Claims trends
o Audit outcomes
o Industry policy insights
o Recommended actions
Clearly communicate findings to business clinical technical and leadership stakeholders.
Act as a trusted advisor on payment integrity and reimbursement policy matters.
Required Skills & Experience
Core Experience
8 years in payment integrity reimbursement policy post payment audits or claims analyticswithin payer or healthcare consulting environments.
Proven ability to independently own complex claims analysis and policy evaluation.
Domain Expertise
Deep knowledge of:
o Provider reimbursement policies
o Clinical edits and coding rules (ICD 10 CM/PCS CPT HCPCS DRG modifiers)
o Payment integrity frameworks and audit methodologies
Strong understanding of industry reimbursement trends and regulatory drivers.
Analytics & Tools
Strong analytical skills using Excel SQL or claims analytics platforms.
Experience with claims adjudication systems such as FACETS or equivalent preferred.
Communication & Advisory Skills
Ability to convert complex data and policy analysis into clear actionable recommendations.
Strong executive communication and stakeholder engagement skills.
Preferred Qualifications
Medical coding certification (CPC CCS CRC or equivalent).
Experience influencing or authoring reimbursement policy decisions.
Exposure to COB DRG HCC or specialty audits. Project Code :