Director Medicare Coverage Analysis

Cleveland Clinic

1d•Onsite

About The Position

Join Cleveland Clinic’s Main Campus where research and surgery are advanced, technology is leading-edge, patient care is world-class, and caregivers are family. Cleveland Clinic is recognized as one of the top hospitals in the country. You will work alongside passionate and dedicated caregivers, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world. Research is a big part of the mission of the Cleveland Clinic. This position will work collaboratively with the institutes and research billing office to create a Medicare coverage analysis billing grid for research studies with a patient care billing component. This is a high-level position to ensure compliance with research billing and mitigate our risks of improper billing and will help standardize the process for coverage analysis for the Cleveland Clinic. A caregiver in this position works 8:00am—5:00pm.

Requirements

Bachelor’s degree in healthcare administration, medical coding, auditing, finance, accounting, nursing, or a related field.
Six years of clinical research experience and an additional four years of management experience (10 years’ experience total).
Knowledge of billing compliance and Medicare regulations.
Excellent oral and written communication skills and can effectively communicate as the MCA subject matter expert with the Principal Investigator, research team, central offices and study Sponsor.
Interpret and comprehend complex clinical research protocols, interpret research contracts, study budgets and consent forms to extrapolate billing/coverage data.
Strong organizational skills with ability to multi-task.
Can manage high volume workload and meet established deadlines.

Nice To Haves

Master’s in business or healthcare administration.
Overall experience and knowledge in coding with CPT.

Responsibilities

Manage and operate all administrative functions performed by the research Medicare coverage analysis team.
Serve as the subject matter expert for the MCA Office and is responsible for determining qualifying clinical trial status and performing detailed coverage analysis as required by NCD 310.1 and the Federal Clinical Trials Policy (CTP).
Ensure research billing practices are compliant by reviewing clinical trial protocols and related regulatory documents and agreements.
Assist all patient care items and service required for each study protocol.
Research and apply policies from various sources such as federal, state, CMS website, and professional practice guidelines in making coverage determinations.
Document justification for coverage analysis by citing specific resources for coverage determinations.
Direct the work activities of all research coverage analysts working in the section ensuring polices from various sources are followed.
Interview, hire, orient, and train staff.
Evaluate performance and provide feedback.
Make personnel action recommendations (e.g., promotions, transfers, disciplinary, discharge).
Review and approve MCA determinations performed by MCA analysts.
Assist in managing claims review by applying the appropriate CDM and/or CPT codes for potentially billable items and services and identifying items and services billable to the research sponsor.
Collaborate and communicate effectively as MCA subject matter expert with the Principal Investigator and research team, patient financial services, clinical research billing office, IRB, and research compliance related to Medicare coverage analysis issues and determinations.
Keep current on FDA and Medicare regulations and state laws that apply to clinical trials research billing and trains MCA analysts.
Generate policies and procedures related to Medicare coverage analysis for the Cleveland Clinic Health System.
Develop tools and billing grids for the Medicare coverage analysis process.