Clinical Payment Policy Analyst — Hybrid

Wellmark Blue Cross and Blue Shield; Des Moines (IA); Híbrido; USD 70 000 - 110 000; Tempo integral

Resumo da oferta

Wellmark Blue Cross Blue Shield is seeking a Payment Policy Analyst - Clinical to join the Payment Integrity team. The role focuses on ensuring provider claims are paid accurately and in line with policy, by reviewing claims, medical records, and supporting documentation.

The ideal candidate is analytical, detail-oriented, and collaborative, with clinical coding knowledge and strong communication skills to translate complex information for stakeholders.

Qualificações

• Associate degree or direct and applicable work experience.
• LPN or RN license in IA or SD (active and unrestricted).
• Coding certification – e.g., CPC, CPC-P, COC, CCS-P, RHIT, or RHIA, or ability to obtain a certification within 6 months of hire.
• Ability to identify issues or inconsistencies; obtain relevant information, relate and 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.
• Demonstrated ability to communicate effectively and professionally, verbally and in writing, expressing complex concepts clearly and concisely to various levels of audiences.
• Demonstrated critical thinking, problem solving/troubleshooting, research, and continuous process improvement skills with the ability to interpret medical policies/procedures and apply analytical and technical knowledge to develop 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 (Outlook, Word, Excel) and ability to learn new software quickly.
• Ability to work independently and cooperatively on teams, maintaining positive relationships with customers.
• Interest in coaching/mentoring others.
• Proficiency in HROR preferred.

Responsabilidades

• Responsible for the research, analysis, development, maintenance, coordination, and documentation of payment policies, interpreting findings from credible sources.
• Monitor healthcare trends, industry publications, and statewide regulations to provide education and potential policy recommendations.
• Review provider payment claim reports daily for reasonableness and trends; document questionable activity and pursue resolution.
• Collaborate with policy vendor and stakeholders to enhance provider payment policies and contribute to savings goals.
• Research, analyze, monitor, and update resolution of high complexity claims, contracting and provider inquiries.
• Ensure coding files are updated with code set revisions, HIPAA-AS standards, and regulatory requirements.
• Support system conversions and release upgrades; provide implementation support and documentation editing.
• Other duties as assigned.

Conhecimentos

Attention to detail

Analytical thinking

Communication skills

Time management

Team collaboration

Adaptable to change

Microsoft Office

Coaching/mentoring

HROR knowledge

Formação académica

LPN or RN license in IA or SD

Associate degree or direct applicable work experience

Coding certification (CPC, CPC-P, COC, CCS-P, RHIT, RHIA)

Ferramentas

Coding certifications listing tools

Descrição da oferta de emprego

Wellmark Blue Cross Blue Shield is seeking a Payment Policy Analyst - Clinical to join the Payment Integrity team. The role focuses on ensuring provider claims are paid accurately and in line with policy, by reviewing claims, medical records, and supporting documentation.

The ideal candidate is analytical, detail-oriented, and collaborative, with clinical coding knowledge and strong communication skills to translate complex information for stakeholders.