Reimbursement Policy Analyst

HealthPartners•Bloomington, MN

About The Position

HealthPartners is hiring a Payment Integrity Reimbursement Policy Analyst responsible for developing, maintaining, implementing, and governing reimbursement policies that support accurate claims adjudication and payment integrity across professional and facility healthcare services. The analyst serves as a subject matter expert in reimbursement methodologies, coding guidelines, payment policies, and regulatory requirements, aligning policy intent with operational claim processing. The role collaborates with Claims Operations, Provider Contracting, Medical Policy, Clinical Operations, Compliance, Legal, Information Technology, and Payment Integrity teams to design, implement, monitor, and optimize policies that promote payment accuracy, regulatory compliance, operational efficiency, and provider transparency. The analyst researches and maintains policies covering professional, facility, laboratory, pharmacy, and ancillary services; interprets Medicare, Medicaid, commercial payer, and industry requirements; and evaluates coding and reimbursement issues. The role also analyzes claims data, payment trends, coding patterns, and audit findings; assesses financial and operational impacts of policy changes; supports pre-payment and post-payment reviews; and helps configure and optimize claims edits and business rules. Additional duties include monitoring regulatory and coding updates, participating in policy governance, preparing reports and presentations, supporting appeals and audits, and documenting policy decisions and payment rationales.

Requirements

Bachelor's degree in Healthcare Administration, Business Administration, Health Information Management, Finance, Public Health, Nursing, or a related field, or an equivalent combination of education and relevant healthcare reimbursement experience.
Minimum 5 years of experience working with HMO, fully insured, indemnity, and government programs.
Prior experience in medical claims processing and adjudication.
Experience using coding software platforms and system editing tools.
Demonstrated ability to independently analyze and adjudicate complex claims scenarios.
CPC, CCA, CCS, or equivalent certification is required.
Strong understanding of health plan claims adjudication processes.
Knowledge of reimbursement methodologies, including Medicare Physician Fee Schedule, APC reimbursement, DRG reimbursement, multiple procedure reductions, bundling and unbundling logic, NCCI edits, and modifier application.
Strong working knowledge of CPT, HCPCS, ICD-10-CM, CMS regulations, LCDs, and NCDs.
Strong analytical and problem-solving skills.
Exceptional written communication and policy development abilities.
Advanced proficiency with Microsoft Excel, Word, PowerPoint, and data-analysis tools.
Ability to make independent decisions and complex judgment calls.
Strong organizational, planning, and prioritization skills.
Effective communication skills across technical and business stakeholders.

Nice To Haves

Bachelor’s degree in a related field.
3–7+ years of healthcare industry experience in one or more of the following areas: Payment Integrity, Reimbursement Policy, Claims Operations, Medical Coding, Provider Reimbursement, Healthcare Revenue Cycle, or Health Plan Operations.
Equivalent combination of education and relevant healthcare reimbursement experience may be considered.
Advanced or specialty coding certifications.
Deep familiarity with coding governance, audit processes, and reimbursement methodologies.
Experience supporting policy development and coding compliance initiatives.

Responsibilities

Research, develop, revise, and maintain reimbursement policies for professional, facility, laboratory, pharmacy, and ancillary healthcare services.
Interpret and apply Medicare, Medicaid, commercial payer, and industry reimbursement requirements.
Evaluate coding and reimbursement issues involving CPT, HCPCS Level II, ICD-10-CM, ICD-10-PCS, DRG, APC, and revenue code methodologies.
Draft clear policy language for provider-facing reimbursement policy documents.
Ensure policies align with organizational objectives, provider contracts, benefit administration requirements, and applicable regulations.
Identify reimbursement opportunities by analyzing claims data, payment trends, coding patterns, and audit findings.
Evaluate financial and operational impacts of proposed reimbursement policy changes.
Monitor payment integrity initiatives and recommend policy enhancements to improve claim payment accuracy.
Support pre-payment and post-payment review activities.
Analyze and resolve complex reimbursement questions escalated from operational teams.
Perform trend analysis to identify billing patterns, reimbursement impacts, and revenue opportunities.
Evaluate coding edits and business rules to ensure optimal system performance.
Identify opportunities to reduce claim inventory and improve financial outcomes.
Support data-driven decision-making through analytics and reporting.
Monitor CMS regulations and guidance, NCCI Policy Manual updates, Medicare National and Local Coverage Determinations, commercial payer practices, and annual CPT and HCPCS updates.
Assess regulatory changes and recommend necessary policy revisions.
Participate in reimbursement policy governance processes.
Maintain documentation supporting policy decisions, implementations, revisions, and approvals.
Prepare reports and presentations on policy initiatives, financial impact, and operational outcomes.
Support continuous improvement efforts across Payment Integrity operations.
Assist with review of provider disputes, reconsiderations, and payment appeals involving reimbursement policy application.
Support internal and external audits related to reimbursement methodologies and payment integrity initiatives.
Provide documentation supporting payment decisions and policy rationale.