About The Position
The Senior Manager, Medical and Payment Policy Performance Research and Correct Coding Analysis independently develops and manages assigned policy and coding reviews by evaluating clinical and payment policies and identifying potential issues. This position ensures coding aligns with defined medical and pre-payment policies, identifies opportunities to optimize performance, and supports organizational goals and regulatory requirements. The role partners closely with claims operations to apply policy intent across end-to-end claims processing (intake, edits, adjudication, denials, appeals, and adjustments) and to drive consistent, compliant outcomes.
Requirements
- 5+ years of experience in healthcare claims administration, coding, or configuration
- Proven expertise in configuration testing, defect management, and process optimization specifically for medical and pre-payment policy.
- Strong analytical, organizational, and problem-solving skills.
- Excellent communication and interpersonal abilities, with experience collaborating across technical and non-technical teams.
- Proficiency with claims adjudication platforms, testing tools, and data analysis applications.
- Bachelor’s degree in Healthcare Administration, Information Systems, Business, or equivalent experience
- Certified Coding Specialist required
Nice To Haves
- Project management certification (e.g., PMP, Lean Six Sigma) preferred
- Experience with system migrations, medical and pre-payment configuration changes, or healthcare technology implementations.
- 3-5 years claims processing systems, including HRP, ACAS and QNXT coding methodologies (ICD, CPT, HCPCS), and regulatory requirements (e.g., CMS, HIPAA).
- Ability to manage multiple priorities in a fast-paced, dynamic environment.
- Commitment to continuous improvement and operational excellence.
- License Practical Nurse (LPN) or Registered Nursing (RN) with active license preferred
Responsibilities
- Collaborate with cross-functional teams—such as IT, compliance, operations, and provider relations—to ensure seamless integration of claims coding changes and resolve complex configuration issues.
- Monitor and report on claims coding and configuration accuracy, trends, and key performance indicators (KPIs), providing actionable insights for process improvement.
- Leverage claims processing experience to evaluate end-to-end workflows (front-end edits, adjudication logic, denials, appeals, and adjustments) and translate findings into actionable policy/coding guidance and claims platform configuration or testing support.
- Stay up to date with industry developments, payer and provider requirements, and regulatory changes affecting claims coding and configuration.
- Develop and maintain documentation for identifying claims trends, pinpointing policy or coding issues, and communicating required configuration changes across claims platforms.
- Lead or participate in audits and reviews related to claims coding and configuration, ensuring readiness and timely resolution of findings.
- Provide expert guidance on correct coding practices, resolving complex coding issues and supporting audits as needed.
Benefits
- medical, dental, and vision coverage
- paid time off
- retirement savings options
- wellness programs
- other resources, based on eligibility.
- CVS Health bonus, commission or short-term incentive program
- equity award program
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Number of Employees
5,001-10,000 employees
