Reporting to the Manager of Payment Policy & Strategy, the Sr. Clinical Policy is responsible for the research, analysis, reporting, development and implementation of custom rules for iCES – HPHC’s claims editing software. This position plays a lead role in the development of all payment and medical policies, including providing technical and methodological design consultation, database maintenance, data management and results interpretation/reporting for iCES savings. This individual will utilize analytic expertise and clinical knowledge to accurately assess industry reimbursement and coding standards and identify opportunities for improvements and cost savings in payment policy, medical policy, quality, operations, and/or utilization.
Assume responsibility for the maintenance of iCES, claims editing database. Build, test and implement custom policy rules within the database, ensuring accurate claim payment according to all payment and medical policies.
Research policies to assess HPHC ability to operationalize and accurately define the financial impact to HPHC and Provider Network related to payment policy and/or medical policy development.
Responsible for all aspects of policy analysis: conceptualization, design, programming, execution, problem identification, and resolution, results, reporting, and recommendations.
Utilize comprehensive knowledge of CPT, HCPCS, ICD9-CM diagnosis and procedure codes, benefit, provider reimbursement and medical policy to assist in implementation of codes, policies, projects as required.
Research and analyze Health Care trends to support Medical Policy, Utilization Management, and Payment Policy decision-making.
Serve as a resource and provide leadership for other team staff on projects and daily operations.
Develop working knowledge of technical and software tools required to access, utilize and analyze data from all HPHC systems environments. Research and stay current on new tools to accommodate continuous changes in technical environment.
Utilizes knowledge of analytic and statistical concepts, techniques and methods in daily work.
Other duties and projects as assigned.
BA/BS, CCS or CPC-H with Inpatient Coding experience. RHIA/RHIT preferred
7+ years experience in health care payment policy design and/or analysis, or equivalent
Licensed nursing professional or clinical experience preferred.
Exceptional knowledge of healthcare delivery system.
Skilled at manipulating and analyzing large data sets.
Knowledge of iCES, or other claims editing software, SAS or other programming language (SQL) and advanced use of MS Access, Excel.
Broad and in-depth knowledge of financial/data analysis and the ability to function independently and creatively.
Ability to manage multiple projects simultaneously
Aptitude for detail-oriented work, proven ability to lead teams and manage complex projects and effective at working with and presenting to all levels of management.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability or protected veteran status.
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