Payment Policy Manager

Site : Mass General Brigham Health Plan Holding Company Inc.

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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 Certified Professional Coder (CPC) with strong claims editing skills and writing skills since this role is writing provider-facing policies and experience with claims editing software (like ClaimsXten). Must have understanding of the claims editing to be successful in this role.

Job Summary

The Opportunity

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 compliments the writer of the claims but setting up our Claims editing process in the Claims editing software system and responding to business needs.

This role works closely with clinical financial and revenue cycle teams to interpret payment policies and provide guidance on reimbursement practices that impact the organizations 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 the 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 CMSs 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 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

Education and Certifications

• Bachelors Degree required
• Certified Professional Coder (CPC) highly preferred
• Can this role consider or review experience in lieu of a degree No

Experience

Skills for Success

Additional Job Details (if applicable)

Working Model Requirements

M-F Eastern Business Hours required

Onsite meetings will be planned ahead quarterly and are preferred not required

Remote employee must work from a stable secure and compliant workstation in a quiet environment. Teams video is required and must be accessed using MGB-provided equipment. Interview process will also require Teams Video access.

Remote Type

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range

$62400.00 - $90750.40 / Annual

Grade

At Mass General Brigham we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive and any offer extended will take into account your skills relevant experience if applicable education certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however it does not encompass all elements contributing to your total compensation addition to competitive base pay we offer comprehensive benefits career advancement opportunities differentials premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

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. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973 the Vietnam Veterans Readjustment Act of 1974 and Title I of the Americans with Disabilities Act of 1990 applicants who require accommodation in the job application process may contact Human Resources at .

Mass General Brigham Competency Framework

At Mass General Brigham our competency framework defines what effective leadership looks like by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance make hiring decisions identify development needs mobilize employees across our system and establish a strong talent pipeline.

Required Experience :

Manager

Key Skills

Legal Drafting,Communication skills,Computer Operation,Business Management,Pricing,Research Experience,Information Security,Project Management,Administrative Experience,Public Speaking,Data Analysis Skills,Writing Skills

Employment Type : Full-Time

Experience : years

Vacancy : 1

Monthly Salary Salary : 62400 - 90750