Professional Provider Reimbursement Policy Manager (Technical Medical Specialist) - PN: 20068616

State of Ohio • Columbus, OH

13h • Hybrid

About The Position

The State of Ohio, Bureau of Workers' Compensation (BWC) is seeking a Professional Provider Reimbursement Policy Manager (Technical Medical Specialist). This role is responsible for leading the development and maintenance of fee schedules and medical reimbursement policies, ensuring accuracy and efficiency in the reimbursement systems. The position involves analyzing operations, designing policies, and providing training to stakeholders. BWC is a state agency with approximately 1,500 employees across seven offices, dedicated to promoting workplace safety and ensuring quality medical care for injured workers. BWC fosters an inclusive workplace and aims to be an agile organization driven by customer success, with a mission to deliver consistently excellent experiences.

Requirements

• Certified medical coder in current procedural terminology (CPT) hospital coding, or current icd coding system; 12 mos. exp in writing medical policies & procedures for medical provider or insurance company; AND 12 mos. practical exp in health care field.
• OR completion of undergraduate program core coursework in pre-medicine, allied medical field, nursing or related field of study; with 12 mos. practical exp. in health care field; AND 12 mos. exp. in writing medical policies & procedures for medical provider or insurance company.
• OR completion of graduate core program in health care administration; AND 12 mos. exp. in medical policy development for medical provider or insurance company.
• OR equivalent of Minimum Class Qualifications for Employment noted above.
• Knowledge of Policy and procedure research and development including Medicare, Federal and State reimbursement regulations, other payer and State reimbursement systems, healthcare laws, regulations and standards, BWC, Divisional & Departmental policies & standard operating procedures; OAC (4123 & 4125) & Ohio Revised Code (4121 & 4123) sections mandating workers’ compensation & provider reimbursement.
• Knowledge of Coding and medical terminology as related to billing and reimbursement: HCPCS and CPT coding; International Classification of Diseases, 10th revisions, Clinical Modification (lCD-10-CM).
• Knowledge of financial and statistical analysis including application of analytics to gather, collate, classify information and problem solve about data, people or things, perform process and outcome analysis, development of complex reports using data warehouse technology and computer software.
• Knowledge of Public & human relations; government structure & process; accounting, finance; healthcare delivery systems and health science administration; health information systems and database management.
• Skill in personal computer; BWC software (e.g. Microsoft Office products).
• Skill in written and oral communication; project management; data collection; analysis and data presentation (spreadsheets, charts, graphs); data warehouse reporting; use of ICD and CPT publications.
• Ability to define problems, collect data, establish facts and draw conclusions.
• Ability to draft and/or edit administrative policies, procedures and directives utilizing Federal methodologies (e.g. Medicare); use investigative, communication and analytical skills to problem solve and develop policy recommendations related to reimbursement; interpret workers’ compensation claims.
• Ability to use statistical analysis and incorporate into fee schedule and reimbursement policy development; analyze hospital, facility and provider bills according to Medicare Prospective Payment System (PPS).
• Ability to apply principles to solve practical, everyday problems.
• Ability to represent, oversee and guide high-volume work unit.
• Ability to deal with a variety of variables in somewhat unfamiliar context.
• Ability to use proper research methods in gathering data.
• Ability to create and interpret complex spreadsheets and analyses; maintain accurate records and databases.
• Ability to prepare meaningful, concise and accurate reports.
• Ability to develop and understand process flows.
• Ability to establish friendly rapport with internal and external customers.
• Ability to effectively communicate and prepare and deliver speeches before specialized audiences and general public.
• Ability to handle sensitive inquiries from and contacts with officials, TPAs, MCOs, providers and general public.

Nice To Haves

• Developed after employment.

Responsibilities

• Lead the development and maintenance of the Professional Provider and Medical Services (PPMS) and other assigned fee schedules (IPPS, OPPS, ASC) aligning with relevant National (i.e., Medicare) and private payer’s methodologies.
• Design and implement medical and reimbursement policies to ensure accurate, efficient, and effective PPMS reimbursement systems.
• Analyze operations and systems to identify improvements and assess the impact of reimbursement methodologies on administrative functions.
• Deliver training sessions for Managed Care Organizations (MCOs) and providers to support accurate billing and administration.
• Serve as the lead expert responding to inquiries and reimbursement approval requests related to PPMS methodologies or other assigned fee schedule.

Benefits

• Medical Coverage
• Free Dental, Vision and Basic Life Insurance premiums after completion of eligibility period
• Paid time off, including vacation, personal, sick leave and 11 paid holidays per year
• Childbirth, Adoption, and Foster Care leave
• Education and Development Opportunities (Employee Development Funds, Public Service Loan Forgiveness, and more)
• Public Retirement Systems ( such as OPERS, STRS, SERS, and HPRS ) & Optional Deferred Compensation ( Ohio Deferred Compensation )

What This Job Offers

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