Reimbursement Policy Analyst III

Texas Children's Hospital • Houston, TX

8h

About The Position

We’re looking for a Reimbursement Policy Analyst III, someone who’s ready to
grow with our company. In this position you will support and develop programs
aligned with Health Plan strategic goals through effective and timely leading
the development, planning, and implementation of new or current medical coding
reimbursement policies leveraging medical coding certification and billing
reconciliation experience. Conducts financial impact analysis based on claim
utilization based on changes to reimbursement policy, MCO notices, Bulletins,
and applicable regulatory guidelines (CMS / 
HHSC / TMPPM / CHIP). Recommends optimal system configuration based on medical
coding billing / reimbursement experience. Leads medical policy meetings and
participates in policy discussion by providing comments and recommendations
orally or in writing.

Think you’ve got what it takes?

Requirements

• Required bachelor's degree
• Required CMC CODE - Cert-Certified Medical Coder
• Required 5 years billing experience, claims processing, and/or configuration of benefits/contracts/fee schedules/medical policy payment rules
• Nine (9) years billing experience, claims processing, and/or configuration experience can substitute a bachelor's degree

Nice To Haves

• Preferred Project Manager Certification
• Preferred 3 years Healthcare industry or MCO environment
• Preferred 3 years Contract / Benefit Engine for Tapestry Certification and 3 years Interpreting complex contract language and intent specific to provider reimbursement

Responsibilities

• Researches, analyzes, and creates health plan reimbursement policy leveraging medical coding certification and billing experience that includes analyzing the regulatory guidelines and converting to creation of medical policy and financial impact analysis.
• Researching & analyzing medical policy and procedures, assessing risks and its impact to dependent areas and providing system optimization recommendation.
• Analyzing and evaluating complex federal and state legislation and creation of financial impact analysis.
• Create technical & non-technical documentation.
• Provide leadership oversight and participation on Medical Expense Review committee on remediation of expense variations as it relates to alignment to regulatory requirements and possible system impacts.
• Applies reimbursement, regulatory, payment integrity, and systems functional knowledge to ensure regulatory adherence for provider reimbursement.
• Research, develop, and implement a coordinated approach to ensure regulatory adherence for the department, through participation in Medical Policy, Reimbursement Committee, Compliance, and other workgroups as needed, provides support for the facilitation of the process and/or system changes.
• Lead the development & implementation of quality processes and procedures in accordance with applicable standards.
• Lead and coordination weekly Payment Operations calls for review of weekly compliance notifications. Provide mentorship and coaching on the interpretation and conversion to system configuration

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level