Research Medicare Coverage Analysis Specialist

Cleveland Clinic • Cleveland, OH

3d • Hybrid

About The Position

The Research Medicare Coverage Analysis Specialist determines qualifying clinical trial status and performs detailed coverage analyses in accordance with NCD 310.1 and the Federal Clinical Trials Policy. The specialist reviews clinical trial protocols and related regulatory documents to assess patient care items and services required by each study and determine the final billing designation for procedures in clinical research projects. The role reports to the Director of Research Medicare Coverage Analysis.

This position is part of a newly established department and will help establish a centralized Medicare Coverage Analysis Office. The office aims to ensure billing compliance, protect the organization and patients, improve operational efficiency, standardize processes, and mitigate risks associated with improper clinical trial billing. The role collaborates with teams across the enterprise and has three openings.

The position follows a hybrid schedule: two to three days per week remotely, with the remaining days on-site at Main Campus. The stated schedule is 8:00 a.m. to 5:00 p.m.

Requirements

• Bachelor’s degree in Healthcare Administration, Medical Coding, Auditing, Finance, Accounting, Nursing, or a related field, plus four years of relevant experience in research billing, compliance, and/or direct involvement with sponsored clinical trials; or six years of relevant experience in those areas in lieu of a degree.
• Excellent oral and written communication skills and ability to communicate effectively with Principal Investigators, research teams, central offices, and study sponsors.
• Ability to interpret and comprehend complex clinical research protocols and interpret research contracts, study budgets, and consent forms to extrapolate billing and coverage data.
• Ability to manage a high-volume workload and meet required deadlines.
• Ability to perform work in a stationary position for extended periods, operate a computer and other office equipment, communicate effectively and exchange accurate information, and travel throughout the health system.
• Follow standard precautions and use personal protective equipment as required for procedures.

Nice To Haves

• Coding or research experience.
• Ability to navigate the CMS website to determine local and national coverage decisions.
• Scientific or healthcare background, such as billing or clinical trials.

Responsibilities

• Determine qualifying clinical trial status and perform coverage analyses required by NCD 310.1 and the Federal Clinical Trials Policy.
• Review clinical trial protocols and related regulatory documents, clinical trial agreements, informed consent documents, FDA and CMS documents, and study budgets to assess patient care items and services required by study protocols.
• Research and apply policies from federal and state sources, the CMS website, and professional practice guidelines when making coverage determinations.
• Document the justification for coverage analyses and cite specific resources supporting determinations.
• Assist with claims review by applying appropriate CDM and/or CPT codes to potentially billable items and services and identifying items and services billable to research sponsors.
• Collaborate and communicate with Principal Investigators, research teams, patient financial services, the clinical research billing office, IRB, and research compliance on coverage-analysis issues and determinations.
• Keep current on FDA and Medicare regulations and state laws applicable to clinical trial research billing.
• Assist the MCA Director in developing tools and billing grids for the Medicare Coverage Analysis process.
• Perform other duties as assigned.

What This Job Offers

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