Payment Policy Manager

Payment Policy Manager

The Payment Policy Manager role is Full Time, within our Reimbursement Strategy department, Mass General Brigham Health Plan. This is a remote role that can be done from most US states. The ideal candidate is a CPC with strong writing skills since this role is writing provider-facing policies and experience with claims editing software (like ClaimsXten).

The Payment Policy Manager is vital to the team and 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 payer-specific 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 organization's financial performance.

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 system-wide decisions.
• Support the maintenance and enhancement of ClaimsXten / CCI information / documentation in Claim Editing Repository.
• Research projects and 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 CMS's semi-annual 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 AllWaysHealthPartners.org 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 cross-functional 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 :

Skills for Success :

Working Model Requirements :

Remote Type : Remote

Work Location : 399 Revolution Drive

Scheduled Weekly Hours : 40

Employee Type : Regular

Work Shift : Day (United States of America)

Pay Range : $62,400.00 - $90,750.40 / Annual

Grade : 6

EEO Statement : Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and / or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.