Research Medicare Coverage Analysis Specialist

Cleveland Clinic; Arkansas; Hybrid; USD 85,000 - 110,000; Full time

Job summary

Cleveland Clinic Main Campus is seeking a Research Medicare Coverage Analysis Specialist to determine qualifying clinical trial status and perform detailed coverage analyses in accordance with NCD 310.1 and Federal Clinical Trials Policy.

You will review protocols, regulatory documents, and budgets to assess patient care items, finalize billing designations, and collaborate with investigators and billing offices while staying current on FDA and Medicare regulations.

Qualifications

• Bachelor’s degree or equivalent in healthcare billing and research compliance.
• Six years of relevant experience in research billing or sponsored trials.
• Strong ability to interpret complex clinical study protocols and budgets.

Responsibilities

• Determine qualifying clinical trial status and perform detailed coverage analyses.
• Review protocols, regulatory documents, and budgets to assess billing items.
• Apply federal and state policies to make coverage determinations.
• Document justification for coverage determinations citing resources.
• Assist in claims review by applying CDM and CPT codes for billable items.
• Collaborate with Principal Investigator and billing offices on Medicare coverage issues.
• Stay current on FDA and Medicare regulations affecting research billing.
• Assist in tool and billing grid development for Medicare Coverage Analysis.

Skills

Analytical skills

Healthcare coding

Research billing

Regulatory compliance

Communication

Education

Bachelor’s degree in Healthcare Administration or related field

Six years experience in research billing or sponsored trials (in lieu of degree)

Four years experience in research billing or sponsored trials

Job description

At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day.

We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One.

Job Title

Research Medicare Coverage Analysis Specialist

Location

Cleveland

Facility

Cleveland Clinic Main Campus

Department

CRAO Central Administration-Research Innov and Educ

Job Code

T97705

Shift

Days

Schedule

8:00am-5:00pm

Job Details

Join Cleveland Clinic’s Main Campus where research and surgery are advanced, technology is leading-edge, patient care is world class and caregivers are family. Here, you will work alongside a passionate and dedicated team, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world.

As a Research Medicare Coverage Analysis Specialist, you willbe responsible fordeterminingqualifying clinical trial status and performing detailed coverage analysesin accordance withNational Coverage Decision NCD310.1 and the Federal Clinical Trials Policy. In this role, you will report to the Director of Research Medicare Coverage Analysis and ensure compliant research billing practices by reviewing clinical trial protocols and regulatory documents to assess all patient care items and services required per the study, as well as determine the final billing designation for all procedures within a clinical research project.

A caregiver in this position works days from 8:00 a.m. – 5:00 p.m.

After the first 90 days, this role transitions to a hybrid schedule with two to three days per week onsite at Main Campus and the remaining days remote.

A caregiver who excels in this role will:

• Make determinations of qualifying clinical trial status and perform detailed coverage analysis as required by NCD 310.1 and the Federal Clinical Trials Policy.
• Ensure compliant research billing practices are followed by reviewing clinical trial protocols, related regulatory documents, clinical trial agreements, informed consent documents, documents from the FDA and CMS, and the study budget to assess all patient care items and services per the study protocol.
• Research and apply policies from various sources such as federal, state, CMSwebsiteand professional practice guidelines in making coverage determinations.
• Document justification for coverage analysis by citing specific resources for coverage determinations.
• Assist in the management of claims review by applying the appropriate CDM and/or CPT codes for potentially billable items and services as well as identifying items and services that are billable to the research sponsor.
• Collaborate andcommunicateeffectively with the Principal Investigator and research team, patient financial services, clinical research billing office,IRBand research compliance related to Medicare coverage analysis issues and determinations.
• Keep current on FDA and Medicare regulations and state laws that apply to clinicaltrials forresearch billing.
• Assist the MCA Director on the development of tools and billing grids for the Medicare Coverage Analysis process.
• Other duties as assigned.

Minimum qualifications for the ideal future caregiver include:

• Bachelor’s degree in Healthcare Administration, Medical Coding, Auditing, Finance, Accounting, Nursing or a related field
• In lieu of degree,six years of relevant experience in research billing, compliance, and/or direct involvement with sponsored clinical trials
• Four years of relevant experience in research billing, compliance, and/or direct involvement with sponsored clinical trials
• Ability to interpret andcomprehendcomplex clinical research protocols, interpret research contracts, studybudgetsand consent forms to extrapolate billing/coverage data
• Strong organizational skills with ability to multi-task

Preferred qualifications for the ideal future caregiver include:

• Ability to navigate CMS website
• Coding experience
• Scientific or healthcare background (i.e. Billing, clinical trials)

Physical Requirements:

• Ability to perform work in a stationary position for extended periods.
• Ability to operate a computer and other office equipment.
• Ability to communicate effectively and exchange accurate information.
• Ability to travel throughout the health system.

Personal Protective Equipment:

• Follows standard precautions using personal protective equipment as required for procedures.

The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances.

Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption.

Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility.

If applying for a Florida position, please see the following website for more information on the background screening requirements required by the Agency of Health Care Administration: https://info.flclearinghouse.com/

Please review the Equal Employment Opportunity poster.

Cleveland Clinic is pleased to be an equal employment opportunity employer.