Claim Payment Policy Lead Nurse (RN) - remote (PA/NJ/DE)

Independence Blue Cross; Philadelphia (Philadelphia County); Remote; USD 80,000 - 100,000; Full time

Job summary

A leading health insurance organization is seeking a Claim Payment Policy Lead Nurse to lead innovations in medical cost opportunities. Responsibilities include developing claims payment policies, collaborating with multiple departments, and ensuring compliance with regulations. Ideal candidates should have a Bachelor’s degree and experience in revenue cycle management. This is a fully remote position for residents in the Tri-State Area of Delaware, New Jersey, or Pennsylvania.

Qualifications

• Minimum of five (5) years related work experience with evidence of a broad base of knowledge and application of the revenue cycle management process.
• Knowledge of medical code sets, including CPT, HCPCS, and ICD-10.
• Must have an Android or iOS device compatible with Microsoft Authenticator app.

Responsibilities

• Lead cross-functional collaborations with key business areas.
• Monitor industry trends and reimbursement practices.
• Develop and maintain claims payment policies.
• Present Policy Bulletins to workgroups and committees.

Skills

Healthcare reimbursement concepts

Excellent organizational skills

Time management

Presentation skills

Analytical skills

Education

Bachelor's degree in relevant discipline

Current coding certification (CCS, CPC, RHIA, RHIT)

Job description

Claim Payment Policy Lead Nurse (RN) - remote (PA/NJ/DE)

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together we will achieve our mission to enhance the health and well-being of the people and communities we serve.

Summary

The Claim Payment Policy Lead is responsible for generating policy driven innovative medical cost opportunities as well as investigating, reviewing, and applying clinical and/or coding expertise in the development and application of reimbursement or medical policies.

Duties and Responsibilities

• Lead cross-functional collaborations with key business areas to generate policy driven innovative medical cost savings ideas, validate feasibility, and execute successful implementation.
• Monitor industry trends, regulatory changes, and reimbursement practices to ensure compliance and alignment with organizational goals.
• Develop and maintain claims payment policies that reflect nationally recognized reimbursement practices in accordance with Company benefit, contracting and reimbursement structures, state and federal mandates and other appropriate sources.
• Develop and maintain select medical policies adapted from Company recognized sources in accordance with Company benefits, state and federal mandates, and other appropriate sources.
• Present Policy Bulletins to appropriate workgroups and committees and revise documents according to recommendations.
• Apply appropriate coding sources to recommend and develop comprehensive code assignments in accordance with established coding guidelines.
• Develop, prepare and present detailed business requirement documents to support policy and coding initiatives.
• Evaluate and analyze utilization patterns and other sources of information to make recommendations for appropriate and cost-effective utilization.
• Develop business cases to assist with decision making for assigned initiatives.
• Mentor other staff and serve as coding and/or clinical SME and represent the department in a variety of forums.
• Interact with all levels of associates and management within the Company and with outside contractors, consultants and other organizations.
• Performs additional related duties as assigned.

Knowledge, Skills, and Abilities Required

• Bachelor's degree in relevant discipline or equivalent work experience.
• Current coding certification (CCS, CPC, RHIA, RHIT), or current coding certification in combination with a clinical licensure (e.g., RN).
• Minimum of five (5) years related work experience with evidence of a broad base of knowledge and application of the revenue cycle management process and medical code sets, including CPT, HCPCS, and ICD-10.
• Knowledge of healthcare reimbursement concepts, health insurance business, industry terminology, and regulatory guidelines.
• Familiarity with Medicare rules and regulations.
• Excellent organizational, time management, presentation, verbal, written and analytical skills and demonstrated ability to develop and lead cross-functional teams.
• Must be able to work independently, prioritize workload, meet deadlines, and to assess the criticality of issues.

Fully Remote: This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence’s physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania.

IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.

Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.

Inclusion and Belonging

At IBX, everyone can feel valued, supported, and comfortable to be themselves, and all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. Celebrating and embracing diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

About Our Company

Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group — together with its subsidiaries — is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day.

At Independence, we see each of our members as an individual, with unique needs and concerns. We’re dedicated to harnessing the very latest ideas and technologies to deliver access to care that meets those needs and surpasses your expectations. For more information about Independence access our website at www.ibx.com. We’re revolutionizing health care, and our focus is on you!

IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.

Agency Disclaimer

All resumes submitted directly to anIndependence Blue Cross employee from a vendor via email, the Internet or in any other form without a valid written search agreement in place for this position from the Independence Blue Cross Family of Companies Human Resources Department will be deemed the sole property of Independence Blue Cross andthe Independence Blue Cross Family of Companies. Please note that no fee will be paid in the event the candidate is hired by Independence Blue Cross orthe Independence Blue Cross Family of Companies as a result of the referral or through means other than our established process.

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