Payment Policy Manager
BMC HealthNet Plan and Well Sense - Boston, MA

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Job Description The Payment Policy Manager is responsible for managing cross-departmental implementation of changes to payment and billing policies as necessary due to regulatory changes, contractual changes, or as a result of claims data findings. The Payment Policy Manager will collaborate with internal departments to define requirements and to document those requirements sufficiently to ensure accurate implementation of payment rules within the Plan’s adjudication system, including the claim editing system, iCES. The Payment Policy Manager will also review current payment policies and compare them to those used by competitors, state regulatory agencies, and CMS to evaluate and recommend changes, and upon approval incorporate such changes into materials. As directed by the department manager, he/she will project manage regulatory changes that impact payment methods or rates, and help drive analytics to support decision-making. Additional specific duties and responsibilities include:

Key Functions/Responsibilities:
  • Develops and maintains corporate payment policies, and works collaboratively with the Clinical Editing Manager to ensure consistency with the Plan’s adjudication system(s).
  • Monitors DHHS, EOHHS, and CMS websites, listservs and other sources to identify existing payment practice and upcoming changes. Determine the scope and impact of the change on Plan operations and seek to implement changes as necessary.
  • Staff and participate in various work groups and committees to support payment policies and provides input into processes and workflows reliant on payment policy outcomes.
  • Serve as the department’s project manager for: (1) regulatory information such as proposed and final Medicare and/or Medicaid payment regulations, Medicare Manual updates, DHHS and EOHHS fee schedules; and (2) regulatory issues. Determine the scope and impact of the information/issues and take appropriate action.
  • Collaborate with Public Partnerships, Contracting, Medical Economics, Provider Relations, Benefit Administration, Business Configuration, and Provider Audit/OPL to determine the impact of implementing recommended policy changes.
  • Develop project plans including: setting timelines and deliverables; determining resource requirements; documents decisions; draft communication plan; information-sharing with appropriate staff and seek approval from the Payment Policy Committee; and subsequently ensure successful completion of change.
  • Serve as the company’s research specialist regarding Medicare and Medicaid payment policies.
  • Serves on the Operational Excellence Committee to ensure a consistent understanding of operational changes as they relate to payment policies and their downstream impact within the Claims department.
  • Submits recommendations to the Payment Policy Committee and supports Committee efforts through subgroups and individually as needed.
  • Collaborate with stakeholder departments to develop and maintain a database to serve a centralized location to store payment methodology information.

  • Bachelor’s Degree in a related field or the equivalent combination of training and experience.
  • AHIMA or other nationally recognized Coding Certification required.
Education Preferred/Desirable:
  • Master’s Degree or graduate work in a related field preferred.
  • Coding Certification for Payers (CPC-P) preferred.
  • 6 or more years experience in a fast paced, managed healthcare environment is required
  • 6 or more years direct work in claims processing, payment policy, or contracting
  • Extensive background of ICD-9 and CPT coding principles
  • Extensive knowledge of medical claim editing (NCCI, etc.)
  • Experience working with industry standard methods of payment including DRG, APC, RVU, etc.
  • Experience working with Medicaid, Medicare and commercial coding rules/ regulatory requirements
Experience Preferred/Desirable:
  • Medical chart auditing
Competencies, Skills, and Attributes:
  • Demonstrated proficiency in coding and knowledge of the requirements of industry standards such as Medicare and/or Managed care regulations required.
  • Strong understanding of HIPAA Guidelines.
  • Good communication skills, both oral and written, ability to interact well with others at all levels, strong organizational skills, strong customer service skills and orientation.
  • Expertise utilizing Microsoft Office products, including Project and Powerpoint
  • Knowledge of OptumInsight iCES product, or similar claims editing system.
Working Conditions and Physical Effort:
  • Regular and reliable attendance is an essential function of the position.
  • Work is normally performed in a typical interior/office work environment.
  • No or very limited physical effort required. No or very limited exposure to physical risk.