Clinical Policy & Government Programs Specialist

Impresiv Health; Tampa (FL); À distance; USD 110 000 - 160 000; Plein temps

Résumé du poste

Impresiv Health is recruiting an experienced Clinical Policy & Government Programs Specialist to support Medicare and Medicaid policy alignment, claims-edit validation, and regulatory compliance. The NP background with coding expertise will translate complex regulations into actionable operational workflows and collaborate with Clinical, Operations, Legal, and Technology teams.

The role emphasizes interpreting NCDs/LCDs, validating CPT/HCPCS rules, and monitoring regulatory updates, with

Qualifications

• Bachelor's degree in Nursing (BSN) and/or MSN.
• 7+ years of relevant professional experience.
• 3+ years in claims editing, payment integrity, coding/auditing, or health plan operations.
• Professional coding certification (CPC, CCS, CPC-P) or equivalent.

Responsabilités

• Review and interpret NCDs, LCDs, and MAC requirements.
• Validate claims-edit configurations against Medicare requirements.
• Verify CPT/HCPCS code exclusions and coverage rules.
• Review monthly regulatory updates and identify required configuration changes.
• Document validation results, elevate discrepancies, and monitor resolution.
• Conduct policy reviews to identify changes from updated Medicare/Medicaid requirements.
• Prepare regulatory change summaries and code-level impact assessments.
• Support policy reconciliation and implementation activities.
• Maintain documentation of policy changes and enforcement requirements.
• Research state Medicaid requirements, coverage mandates, and applicable legislation.
• Translate legislative/regulatory changes into actionable recommendations.
• Serve as SME for Medicare, Medicaid, and clinical policy requirements.
• Collaborate with clinical leadership, legal teams, and operations.
• Support client implementations, policy discussions, and regulatory presentations.
• Evaluate state mandate requests and recommend policy or operational considerations.
• Develop and maintain SOPs, documentation, and regulatory controls.
• Identify opportunities to improve policy monitoring, validation, and reporting processes.
• Explore automation and AI-assisted tools to improve regulatory research and analysis.
• Collaborate across departments to strengthen compliance and operational consistency.

Connaissances

Regulatory knowledge

Analytical skills

Attention to detail

Documentation

Cross-functional collaboration

Excel proficiency

Communication

Formation

Bachelor's degree in Nursing (BSN)

Master of Science in Nursing (MSN)

Outils

JIRA

SharePoint

SQL

Description du poste

Employment Type: Full-Time | Direct Hire

Location/Schedule: Remote with occasional travel to Tampa, FL.

Description:

Impresiv Health is partnering with a leading healthcare technology and services organization to recruit an experienced Clinical Policy & Government Programs Specialist.

Our client supports health plans nationwide by improving the accuracy, efficiency, and clinical appropriateness of healthcare services through evidence-based policies, regulatory expertise, and advanced technology.

We are seeking a detail-oriented clinical professional with strong regulatory knowledge, coding expertise, and analytical capabilities to support Medicare and Medicaid policy alignment, claims-edit validation, and regulatory compliance.

The ideal candidate is a Nurse Practitioner (NP) with professional coding experience who understands how Medicare coverage determinations, state Medicaid requirements, and regulatory changes translate into operational processes and claims payment decisions.

This individual will collaborate with Clinical, Operations, Legal, and Technology teams to ensure policies remain accurate, compliant, and consistently implemented.

What You Will Do:

• Review and interpret National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Administrative Contractor (MAC) requirements.
• Validate claims-edit configurations against applicable Medicare coverage requirements.
• Verify CPT and HCPCS code exclusions, coverage restrictions, and jurisdiction-specific rules.
• Review monthly regulatory updates and identify required configuration changes.
• Document validation results, elevate discrepancies, and monitor resolution.

Clinical Policy Review & Regulatory Alignment

• Conduct policy reviews to identify changes resulting from updated Medicare and Medicaid requirements.
• Evaluate differences between existing clinical policies and newly published coverage guidelines.
• Prepare regulatory change summaries and code-level impact assessments.
• Support policy reconciliation and implementation activities.
• Maintain accurate documentation of policy changes and enforcement requirements.

State Medicaid & Government Programs

• Research and interpret state Medicaid requirements, coverage mandates, and applicable legislation.
• Maintain state-specific regulatory reference materials and compliance tracking tools.
• Identify potential conflicts between organizational policies and state Medicaid requirements.
• Support regulatory research and implementation activities as additional states and programs are introduced.
• Translate legislative and regulatory changes into actionable operational recommendations.
• Serve as a subject matter resource for health plan clients regarding Medicare, Medicaid, and clinical policy requirements.
• Research client questions and prepare clear, accurate, and actionable responses.
• Collaborate with clinical leadership, legal teams, and operational stakeholders to address complex regulatory issues.
• Support client implementations, policy discussions, and regulatory presentations.
• Evaluate state mandate requests and recommend appropriate policy or operational considerations.

Process Improvement & Quality Assurance

• Develop and maintain standard operating procedures (SOPs), documentation, and regulatory controls.
• Identify opportunities to improve policy monitoring, validation, and reporting processes.
• Support quality assurance, auditing, and operational improvement initiatives.
• Explore automation and AI-assisted tools to improve regulatory research and analysis.
• Collaborate across departments to strengthen compliance and operational consistency.

You Will Be Successful If:

• You have strong analytical judgment, attention to detail, and documentation skills.
• You can interpret complex Medicare and Medicaid regulations and translate requirements into operational workflows.
• You communicate complex regulatory topics clearly to nonclinical stakeholders.
• You can identify regulatory discrepancies, document findings, and support resolution.
• You can collaborate with Clinical, Operations, Legal, and Technology teams to maintain policy accuracy and operational consistency.

What You Will Bring:

• Bachelor's degree in Nursing (BSN) and/or Master of Science in Nursing (MSN).
• Previous or active, unrestricted U.S. Nurse Practitioner (NP) license.
• 7+ years of relevant professional experience.
• 3+ years of experience in claims editing, payment integrity, coding/auditing, utilization review, or health plan operations.
• Professional coding certification (CPC, CCS, CPC-P) or equivalent coding experience.
• Strong knowledge of CPT, HCPCS, and ICD-10 coding systems.
• Demonstrated understanding of Medicare NCDs, LCDs, MAC jurisdictions, and Medicaid requirements.
• Experience interpreting regulatory guidance and translating requirements into operational workflows.
• Advanced Excel proficiency, including lookups, large datasets, and comparative analysis.
• Excellent written and verbal communication skills, particularly when explaining complex regulatory topics to nonclinical stakeholders.
• Strong analytical judgment, attention to detail, and documentation skills.

Preferred Qualifications

• Experience with laboratory benefits, molecular diagnostics, or genetic testing policies.
• Experience with claims-editing or payment integrity platforms.
• Direct experience supporting health plan clients.
• Familiarity with JIRA, SharePoint, and policy documentation systems.
• SQL or other data validation experience.
• Background in quality assurance, compliance auditing, or clinical policy administration.
• Experience collaborating with Clinical, Operations, Legal, and Technology teams.
• Ability to work independently, navigate ambiguity, and establish effective processes.

About Impresiv Health:

Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve our most complex business challenges.

Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do–provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.