Healthcare Claims Payment Policy Managing Consultant

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Clearance Required:

We are looking for a Healthcare Claims Payment Policy expert to draft standardize implement and maintain payment policies that improve payment accuracy cost control provider experience and compliance in a large payer this role you will help shape how reimbursement policies are researched written operationalized and communicated across clinical operational finance legal analytics and implementation stakeholders. You will translate reimbursement research claims data stakeholder input and policy decisions into clear operationally usable guidance that supports consistent claims adjudication and stakeholder understanding. The ideal candidate brings strong payer and provider reimbursement policy experience including knowledge of Medicare Medicaid TRICARE commercial payer policy provider billing standards claims coding modifiers fee schedules and reimbursement impact analysis.

What You Will Do:

• Support the payment policy workstream. Set priorities manage the policy portfolio align stakeholders and drive timely decisions that support accurate and consistent reimbursement.

• Draft and standardize payment policies. Write update and maintain clear payment policies reimbursement guidance FAQs briefings and implementation materials.

• Translate policy into operational requirements. Convert reimbursement policy payer guidance coding requirements and stakeholder decisions into claims rules edits bundles business requirements payment controls fee schedules and operational decision logic.

• Support implementation and stakeholder adoption. Coordinate readiness communications testing support reimbursement logic clarification issue resolution and stakeholder materials so policies are understood and applied consistently.

• Monitor reimbursement policy changes. Track federal state and commercial payer updates coding changes fee schedule changes and provider billing guidance to keep policies current.

• Analyze reimbursement and claims impact. Define data needs review claims and reimbursement data assess payment impacts and use findings to inform policy decisions implementation planning and stakeholder discussions.

What You Will Need:

• 5 years in payment policy reimbursement policy payment integrity claims revenue cycle fee schedule development or healthcare reimbursement.

• Experience drafting standardizing implementing and maintaining payment policies reimbursement guidance provider billing guidance and stakeholder communications.

• Knowledge of Medicare Medicaid TRICARE commercial payer reimbursement policy provider billing standards fee schedules claims adjudication rules and healthcare claims coding concepts including CPT HCPCS ICD revenue codes DRGs modifiers bundled payments unlisted codes non-reimbursable codes and claims edits.

• Ability to translate reimbursement policy and payer guidance into claims rules edits bundles business requirements payment controls operational decision logic and defensible payment integrity approaches.

• Ability to translate policy questions into data requests interpret claims and reimbursement data and clearly explain operational and payment impact to technical and non-technical stakeholders.

What Would Be Nice To Have:

• Experience working in a large federal health payer or provider environment with complex reimbursement policies multiple stakeholders and cross-functional implementation partners.

• Experience supporting third-party administrator or claims operations implementation including translating policy into business requirements clarifying reimbursement logic supporting testing resolving operational questions and tracking implementation issues.

• Experience conducting claims reimbursement cost or payment impact analyses using Excel Power BI Tableau SQL or similar tools.

• Experience leading a team or workstream including setting priorities assigning work reviewing deliverables coordinating subject matter experts tracking deadlines and communicating status risks and decisions to leadership.

• Preference will be given to candidates local to the Washington DC metro area.

What We Offer:

Guidehouse offers a comprehensive total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace.

Benefits include:

• Medical Rx Dental & Vision Insurance

• Personal and Family Sick Time & Company Paid Holidays

• Position may be eligible for a discretionary variable incentive bonus

• Parental Leave and Adoption Assistance

• 401(k) Retirement Plan

• Basic Life & Supplemental Life

• Health Savings Account Dental/Vision & Dependent Care Flexible Spending Accounts

• Short-Term & Long-Term Disability

• Student Loan PayDown

• Tuition Reimbursement Personal Development & Learning Opportunities

• Skills Development & Certifications

• Employee Referral Program

• Corporate Sponsored Events & Community Outreach

• Emergency Back-Up Childcare Program

• Mobility Stipend

About Guidehouse

Guidehouse is an Equal Opportunity EmployerProtected Veterans Individuals with Disabilities or any other basis protected by law ordinance or regulation.

Guidehouse will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco.

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Guidehouse does not accept unsolicited resumes through or from search firms or staffing agencies. All unsolicited resumes will be considered the property of Guidehouse and Guidehouse will not be obligated to pay a placement fee.