Payment Policy Analyst - Clinical (LPN or RN required)

Wellmark•Des Moines, IA

10d•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 and investigate inconsistencies. It applies claims, coding, and medical terminology knowledge to research complex issues, develop evidence-based recommendations, and communicate clinical information as actionable insights. The analyst collaborates with Payment Integrity partners, Medical Directors, Medical Policy, providers, and other stakeholders to improve payment policies and processes. The position researches, analyzes, develops, maintains, coordinates, and documents payment policies; monitors healthcare trends and regulations; reviews claim reports and complex claims; and supports coding-file updates, system conversions, release upgrades, and process documentation. The position follows a hybrid schedule, working at least three days (Tuesday through Thursday) in Wellmark’s Des Moines office and with the option to work remotely on Monday and Friday.

Requirements

Associate degree or direct and applicable work experience.
Active, unrestricted Iowa or South Dakota LPN license, or active, unrestricted Iowa or South Dakota RN license; the individual must be licensed in their state of residence.
Coding certification (for example, CPC, CPC-P, COC, CCS-P, RHIT, or RHIA), or ability to obtain 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 or accreditation standards or guidelines, including interpretation of technical specifications for data-file and system upgrades.
Effective and professional verbal and written communication, 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 to stakeholders.
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.

Nice To Haves

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

Responsibilities

Research, analyze, develop, maintain, coordinate, and document payment policies.
Use established sources, the Internet, and peer-reviewed articles to interpret and summarize research findings, 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, and ensure claims are paid accurately and efficiently according to payment policies.
Identify and document questionable activity proactively and work with others to resolve it.
Work with the payment policy vendor to improve the claims payment process and contribute to Wellmark’s benefit savings goal.
Collaborate with providers, Network Engagement Business Partners, Medical Directors, and other Wellmark stakeholders to develop and enhance provider payment policies.
Research, analyze, monitor, and update resolution of 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 with business expertise, implementation support, and editing-process documentation.
Perform other duties as assigned.