Claim Payment Policy Lead

Claim Payment Policy Lead

Location : Remote ( must reside in PA, NJ, or DE

Duration : 3+ months, potential for temp-to-perm

Compensation : $40-$50 / hour based on experience and license

Equipment : Candidate must provide their own

Role Overview We are seeking a strategic and detail-oriented Claim Payment Policy Lead to drive the development and alignment of claim payment policies across payer systems. This is a policy-focused role—not a chart audit position—designed to monitor industry trends, reduce cost escalation, and improve affordability and health outcomes for members.

Key Responsibilities

Lead cross-functional initiatives to identify and implement cost-saving opportunities through policy innovation

Monitor reimbursement trends, regulatory updates, and payer practices to ensure policy alignment and compliance

Develop and maintain claim payment policies and select medical policies based on nationally recognized standards and organizational frameworks

Present policy bulletins to internal committees and revise documentation based on feedback

Apply coding expertise to create comprehensive code assignments aligned with established guidelines

Draft and present detailed business requirement documents to support policy and coding strategies

Analyze utilization data to recommend cost-effective practices and support decision-making with business cases

Serve as a subject matter expert (SME) in coding and clinical policy, mentoring team members and representing the department across forums

Collaborate with internal teams and external partners, including consultants and contractors

Qualifications

Minimum 3 years of clinical experience; RN preferred, but LPNs and allied health professionals (e.g., PT) are welcome

3–5 years of medical coding experience with one or more certifications : CPC, CCS, RHIA, or RHIT

Background in provider physician billing or facility billing

Strong organizational, analytical, and communication skills, with proven ability to lead cross-functional teams

Self-starter with excellent time management and prioritization abilities