IBR Policy and Content Development Analyst

Jobgether; EUA; Teletrabalho; USD 85 000 - 110 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Fully remote work

Medical coverage

Dental and vision insurance

401(k) plan

Tuition reimbursement

Flexible spending / Health savings

Wellness perks

Professional growth

Inclusive workplace

Resumo da oferta

Jobgether is seeking an IBR Policy and Content Development Analyst based in the United States. The role strengthens healthcare payment integrity through accurate clinical policy development, audit concepts, and regulatory compliance.

You will work with clinical, coding, operations, client services, and IT teams to translate payment policies into reliable audit logic, improve reimbursement accuracy, and support scalable, AI-powered research and documentation.

Qualificações

• At least three years in healthcare payment integrity or related field.
• Active certification/license in RHIA/RHIT/CCS/CPC/CPMA or RN/LPN acceptable.
• Interpret complex regulations and translate into compliant content.
• Knowledge of Medicare and commercial coding rules and reimbursement policies.
• Understand facility reimbursement models and policies.
• Strong research, data analysis, and problem-solving skills.
• Ability to develop and validate audit rules and policy documents.
• Experience with AI/automation in policy development.
• Proficient in Microsoft Office applications.
• Excellent written and verbal communication skills.
• Strong organizational and prioritization abilities.
• Proactive in continuous improvement and adapting to regulatory changes.
• Remote work readiness for a fully remote role in the United States.

Responsabilidades

• Develop and maintain audit concepts updated per schedules and client needs.
• Research regulatory and coding guidance and document findings clearly.
• Apply payer-specific reimbursement rules and contractual requirements.
• Interpret state Medicare/Medicaid manuals and regional guidelines.
• Identify new audit opportunities from payer policies and trends.
• Maintain concepts across Medicaid, Medicare, and commercial programs.
• Ensure audit concepts align with CMS guidance, MUEs, CPT/HCPCS.
• Develop auditing for NCCI unbundling.
• Analyze audit performance and root cause with cross-functional teams.
• Benchmark outcomes against industry standards and client baselines.
• Validate automated audit logic before deployment.
• Ensure concepts reflect current coding guidelines and payment methods.
• Promote consistent policy application across platforms and workflows.
• Collaborate on policy improvements with clinical, coding, and IT teams.
• Improve workflows, documentation, and cross-functional coordination.
• Leverage AI to accelerate policy research and scalability.

Conhecimentos

Regulatory policy

Medical coding knowledge

Claims & reimbursement

Analytical thinking

AI & automation

MS Office

Communication

Organization

Remote work readiness

Formação académica

RHIA/RHIT/CCS/CPC/CPMA certification

RN/LPN license

Ferramentas

Excel

AI tools

Policy documentation tools

Descrição da oferta de emprego

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for an IBR Policy and Content Development Analyst based in the United States.

As an IBR Policy and Content Development Analyst, you will play a key role in strengthening healthcare payment integrity through accurate clinical policy development and claims auditing solutions.

You will leverage your expertise in medical coding, facility billing, reimbursement methodologies, and regulatory requirements to develop, validate, and optimize audit concepts.

Working closely with clinical, coding, operations, client services, and technology teams, you will ensure that payment policies are translated into reliable, compliant, and effective audit logic.

You will analyze regulatory updates, payer guidelines, and claims data to identify opportunities for improvement and develop solutions that support accurate reimbursement.

Your work will contribute to reducing improper healthcare payments, improving operational efficiency, and helping health plans manage costs more effectively.

You will also leverage AI-powered tools and automation to streamline research, improve documentation, and enhance the scalability of payment integrity solutions.

This fully remote opportunity is ideal for a detail-oriented healthcare professional who combines strong analytical skills with regulatory expertise and a commitment to improving payment accuracy.

Accountabilities

• Develop and maintain audit concepts: Review, update, and enhance existing audit concepts according to established review schedules and in response to client requirements, regulatory changes, and evolving coding standards.
• Research regulatory and coding requirements: Analyze changes in healthcare regulations, medical coding guidelines, reimbursement methodologies, and payer policies to assess their impact on existing audit concepts and document findings clearly.
• Apply client-specific policies: Interpret and incorporate payer-specific reimbursement rules, medical necessity criteria, and contractual requirements into audit concept reviews and updates.
• Interpret government and regional policies: Research and apply state-specific Medicare and Medicaid provider manuals, regional regulatory requirements, and applicable government payment guidelines to audit configurations.
• Identify new audit opportunities: Evaluate payer policies and claims trends to identify coverage gaps, reimbursement inconsistencies, and opportunities to propose new audit concepts to clients.
• Support multiple payment programs: Ensure audit concepts are appropriately developed and maintained across Medicaid, Medicare, and commercial insurance programs, taking into account the distinct requirements of each offering.
• Maintain coding and regulatory compliance: Align audit concepts with applicable industry standards, including Centers for Medicare & Medicaid Services (CMS) guidance, Medically Unlikely Edits (MUEs), CPT and HCPCS coding guidelines, and other relevant payment rules.
• Develop coding unbundling audits: Create, validate, and maintain audit concepts that identify inappropriate coding unbundling in accordance with National Correct Coding Initiative (NCCI) edits.
• Analyze audit performance: Investigate discrepancies in concept outcomes and collaborate with clinical, coding, and operations teams to determine root causes and implement corrective actions.
• Benchmark and optimize results: Compare audit outcomes against industry standards, historical performance, and client-specific baselines to identify performance gaps and opportunities for improvement.
• Validate automated audit logic: Participate in testing new and updated concepts to confirm that automated rules perform accurately within system environments before deployment.
• Ensure pre-deployment accuracy: Verify that audit concepts reflect current coding guidelines, payment methodologies, and payer policies before implementation.
• Promote consistent policy application: Support audit teams in applying policies accurately and consistently across technology platforms, client programs, and operational workflows.
• Collaborate on payment integrity initiatives: Partner with clinical, coding, operations, client services, and IT teams to develop audit strategies, clinical and coding solutions, and policy improvements.
• Improve workflows and documentation: Identify opportunities to streamline audit concept development, strengthen documentation standards, improve tracking processes, and enhance cross-functional coordination.
• Leverage AI and automation: Use AI-powered tools and automation platforms to accelerate policy research, support clinical content development, improve operational efficiency, and scale payment integrity solutions.
• Support additional business priorities: Contribute to ad hoc projects and other responsibilities as needed to support organizational objectives.

Requirements

• Relevant industry experience: At least three years of experience in healthcare payment integrity, facility claims auditing, or a closely related field.
• Required professional certification or license: At least one of the following credentials: Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Professional Coder (CPC), or Certified Professional Medical Auditor (CPMA). An active Registered Nurse (RN) or Licensed Practical Nurse (LPN) license is also accepted.
• Regulatory policy expertise: Demonstrated ability to interpret complex healthcare regulations, payer guidelines, and medical requirements and translate them into clear, compliant clinical content and structured policy documentation.
• Medical coding knowledge: Strong understanding of Medicare and commercial coding rules, reimbursement regulations, prospective payment systems, and national coding standards, particularly those related to healthcare payment policies.
• Claims and reimbursement expertise: Broad knowledge of medical claims billing and payment systems, facility billing guidelines, provider reimbursement rules, payer policies, medical necessity criteria, and medical coding terminology.
• Facility reimbursement methodologies: In-depth understanding of different facility reimbursement models and commercial and government payment policies, with the ability to support contractual compliance and audit accuracy.
• Analytical and research capabilities: Strong research, data analysis, and problem-solving skills, including the ability to assess claims information, evaluate audit performance, identify discrepancies, and recommend improvements.
• Technical documentation skills: Ability to develop, maintain, and validate audit rules, code lists, policy documents, and structured clinical content with a high degree of accuracy and attention to detail.
• AI and automation proficiency: Demonstrated experience using AI tools or automation platforms to improve clinical research, streamline policy development, or enhance operational workflows.
• Microsoft Office proficiency: Strong working knowledge of Microsoft Office applications, including Excel, Word, Outlook, PowerPoint, SharePoint, and Teams.
• Communication and collaboration: Excellent written and verbal communication skills, with the ability to explain complex regulatory and coding requirements to colleagues, cross-functional teams, and clients at different organizational levels.
• Organization and prioritization: Strong organizational skills and the ability to manage multiple projects, balance competing priorities, meet deadlines, and maintain accurate documentation.
• Adaptability and continuous improvement: A proactive approach to identifying process improvements, responding to changing regulatory requirements, and collaborating with colleagues to strengthen audit effectiveness.
• Remote work readiness: Ability to work independently in a fully remote environment while maintaining effective communication and coordination with distributed teams across the United States.

Benefits

• Competitive base salary: Annual salary ranging from $85,000 to $110,000, depending on skills, experience, qualifications, and geographic location.
• Fully remote work: The flexibility to work remotely from anywhere within the United States.
• Medical coverage: Access to comprehensive medical insurance options.
• Dental and vision insurance: Benefits designed to support employees' overall health and well-being.
• Flexible spending and health savings accounts: Access to FSA and HSA options to help manage eligible healthcare expenses.
• Retirement savings: A 401(k) plan with employer matching contributions.
• Tuition reimbursement: Financial support for eligible educational and professional development opportunities.
• Health and wellness perks: Additional benefits and resources designed to support personal well-being.
• Flexible and supportive environment: A digital-first workplace that encourages autonomy, collaboration, and the ability to perform at your best.
• Professional growth: Opportunities to develop expertise in healthcare regulations, coding methodologies, payment integrity solutions, and AI-enabled workflows.
• Inclusive workplace: A commitment to equal employment opportunity and reasonable accommodations throughout the recruitment and employment process.

We appreciate your interest and wish you the best!

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