Payment Policy Analyst - Clinical

Wellmark, Inc. • Des Moines, IA

13d • Hybrid

About The Position

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

This is a hybrid position requiring at least three days per week (Tuesday through Thursday) in Wellmark’s Des Moines office, with the option to work remotely Monday and Friday.

Requirements

• Associate degree or direct and applicable work experience.
• An active, unrestricted Licensed Practical Nurse (LPN) license in Iowa or South Dakota, or an active, unrestricted Registered Nurse (RN) license in Iowa or South Dakota; the individual must be licensed in their state of residence.
• Coding certification such as CPC, CPC-P, COC, CCS-P, RHIT, or RHIA, or the ability to obtain a certification within six months of hire.
• Ability to identify issues or 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 varied audiences.
• Critical-thinking, problem-solving and troubleshooting, research, and continuous process improvement skills, including the 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 the 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 relationships with customers.

Nice To Haves

• Interest in coaching or mentoring others.
• Claims and/or coding knowledge.
• Varied clinical experience.

Responsibilities

• Research, analyze, develop, maintain, coordinate, and document payment policies; interpret and summarize research findings using established 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 according to payment policies, and document questionable activity while working with others toward resolution.
• Collaborate with a payment policy vendor to enhance the claims payment process and contribute to Wellmark’s benefit savings goal.
• Work with providers, Network Engagement Business Partners, Medical Directors, and other Wellmark stakeholders to develop and enhance provider payment policies.
• Research, analyze, monitor, and update the resolution of high-complexity claims, contracting issues, 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 process needs.
• Provide business expertise and support for system conversions and release upgrades, including implementation support and editing process documentation.
• Perform other duties as assigned.

What This Job Offers

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