Prov Reimb Policy Spec Sr

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

Your career starts now. We're looking for the next generation of health care leaders.

At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you.

Headquartered in Newtown Square, PA, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.

Role Overview

The Medical Policy Reimbursement Department (MPR) is responsible for maintenance and development of clinical edits and the corresponding reimbursement policies that promote accurate and consistent claim payment determinations across the enterprise. Aligning with industry standards as well as state and federal regulations to ensure claims processing integrity. The MPR department also ensures that all policies are easily accessible to internal stakeholders and network providers. The Senior Medical Policy Specialistindependently interacts with the internal business partners to support inquiries, internal editing function reviews, the development of new policies and coordination of plan policy and edit approvals.

Work Arrangement

• Remote role
• Monday through Friday, 8:30 AM EST to 5:00 PM EST

Responsibilities

• Creates and maintain standardized documentation for medical and clinical claim payment policies and edits.
• Research and advise on Medical Coding including CMS, State Medical Agencies, AMA/CPT, HCPS, ICD-10.
• Translate health care benefits to the procedure code level to support enterprise and internal processes.
• Act as a liaison between Payment Integrity vendors and the internal business teams to Implement, Test and Troubleshoot Medical Policy Reimbursement.
• Research, create and compose Reimbursement Policies.
• Review and validate annual changes required for existing Reimbursement policies
• Assist in the development and implementation of new claim reimbursement edits for all vendors, corporate initiatives and Facets configuration teams.
• Coordinate testing of Reimbursement Edits with outside Vendors and Internal Resources
• Assist the Team Lead with implementation of reimbursement edits and policies for new Markets
• Perform analytics of Reimbursement Edits across systems and vendors to mitigate duplication and conflicts ensure effective edit application.
• Navigate the CMS databases and manuals for Medicare and Medicaid for change impacts and edit conflicts
• Facilitate meetings to promote communication, education and synergy within the Medical Policy Reimbursement and Plan Network Operations Team.
• Support the Medical Policy Reimbursement Team in researching and identifying edit discrepancies and providing corrective action to remedy claims payment issues as they relate to edits.
• Mentors/trains Medial Policy Specialist.

Education and Experience

• Associate’s Degree or equivalent experience in Medical Policy and Reimbursement Claim Edits.
• Registered Health Information Administrator (RHIA); or Certified Coding Specialist (CCS); or Certified Professional Coder (CPC) + Certified Professional Coder-Hospital (COC)
• 10 or more years in Claim Auditing, Claims Billing, Medical Loss Review or Fraud, Waste and Abuse position within a medical facility, medical insurance carrier or Managed Care Organization or provider contracting configuration and maintenance.
• 10 or more years in a Business Analyst function with a medical insurance carrier operations team, preferably managed care operations.

Other Skills:

• Medicaid, Medicare and Commercial Insurance experience
• Must have expert skills utilizing Microsoft Office programs. SharePoint, MS Access or SQL is desired
• Ability to work with all levels of staff from Analysts to Senior VPs

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.