Payment Policy Analyst - Clinical (LPN or RN required)

Wellmark, Inc. • Des Moines, IA

11d • Hybrid

About The Position

The Payment Policy Analyst works within Wellmark’s Payment Integrity team to help ensure provider claims are paid accurately, efficiently, and in accordance with payment policies. The role reviews provider payment inquiries, claims, medical records, and supporting documentation to identify trends, investigate inconsistencies, and understand the causes of claim outcomes. It applies knowledge of claims, coding, and medical terminology to research complex issues, develop well-supported recommendations, and translate clinical information into actionable insights. The analyst collaborates with Payment Integrity partners, Medical Directors, Medical Policy, providers, and other stakeholders to enhance payment policies and processes.

The position requires varied clinical experience and a curious, analytical, detail-oriented approach. Claims or coding knowledge is helpful, particularly for reviewing complex medical records and interpreting diagnosis codes, modifiers, and related claim information. The role also monitors healthcare trends and regulations, analyzes high-complexity claims and inquiries, supports system changes, and contributes to payment-process improvements.

This is a hybrid position based in Wellmark’s Des Moines office. The schedule is at least three days in the office (Tuesday, Wednesday, and Thursday), with the option to work remotely on Monday and Friday.

Requirements

• Associate degree or direct and applicable work experience.
• An active, unrestricted Iowa or South Dakota LPN or RN license; the individual must be licensed in their state of residence.
• Coding certification such as CPC, CPC-P, COC, CCS-P, RHIT, or RHIA, or ability to obtain a certification within six months of hire.
• Ability to identify issues and inconsistencies, obtain relevant information, compare data from different sources, and identify alternative solutions.
• Understanding of regulatory standards, accreditation standards, or guidelines, including interpretation of technical specifications for data-file and system upgrades.
• Effective and professional verbal and written communication skills, including the ability to explain complex concepts clearly and concisely to different audiences.
• Critical thinking, problem-solving and troubleshooting, research, and continuous process improvement skills; ability to interpret medical policies and procedures and apply analytical and technical knowledge to develop and communicate recommendations.
• Self-starter with effective time-management skills and ability to organize and prioritize competing projects or tasks; flexible and adaptable to change.
• Proficiency with Microsoft Office, such as Outlook, Word, and Excel, and technical aptitude to learn new software quickly.
• Ability to work independently and cooperatively on teams while maintaining positive customer relationships.
• Interest in coaching or mentoring others.
• Varied clinical experience.

Nice To Haves

• Claims and/or coding knowledge, particularly for reviewing complex medical records and interpreting diagnosis codes, modifiers, and other claim information.
• Proficiency in HROR.

Responsibilities

• Research, analyze, develop, maintain, coordinate, and document payment policies; interpret and summarize findings from standard sources, the Internet, and relevant peer-reviewed articles, including demographic, statistical, and scientific information.
• Monitor healthcare trends, industry publications, and statewide regulations to provide education and potential payment policy recommendations.
• Review provider payment claim reports daily for reasonableness and trends, ensure claims are paid accurately and efficiently under payment policies, and identify and document questionable activity for resolution.
• Collaborate with the payment policy vendor to enhance claims payment processes and contribute to Wellmark’s benefit savings goal.
• Work with providers, Network Engagement Business Partners, Medical Directors, and other stakeholders to develop and enhance provider payment policies.
• Research, analyze, monitor, and update resolutions for high-complexity claims, contracting matters, and provider inquiries.
• Update coding files as required by code set revisions, HIPAA-AS, medical policy development and implementation, regulatory requirements, FEP and Blue Card guidelines, or other internal processes.
• Support system conversions and release upgrades by providing business expertise, implementation support, and editing process documentation.
• Perform other duties as assigned.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree