Research Medicare Coverage Analysis Specialist

Cleveland Clinic; Cleveland (OH); Hybrid; USD 58,000 - 88,000; Full time

Job summary

Cleveland Clinic’s 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 the Federal Clinical Trials Policy. You will report to the Director of Research Medicare Coverage Analysis and ensure compliant research billing practices for all procedures within a clinical study.

A caregiver works days 8:00 a.m.–5:00 p.m.

Qualifications

• Bachelor’s degree or equivalent in healthcare/finance-related field.
• Ability to interpret complex clinical research protocols and budgets.
• Strong organizational and multitasking capabilities.

Responsibilities

• Make determinations of qualifying clinical trial status and perform detailed coverage analyses per NCD 310.1.
• Review clinical trial protocols, regulatory documents, and budgets to assess patient care items and services.
• Apply federal, state, CMS guidelines to make coverage determinations.
• Document justification for coverage decisions with cited resources.
• Assist in claims review by applying CDM and CPT codes for billable items.
• Collaborate with Principal Investigator and research team to resolve Medicare coverage issues.
• Stay current on FDA and Medicare regulations impacting research billing.

Skills

Organizational skills

Multi-tasking

Interpret complex protocols

Education

Bachelor’s degree in Healthcare Administration or related field

Job description

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 will be responsible for determining qualifying clinical trial status and performing detailed coverage analyses in accordance with National 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, CMS website and 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 and communicate effectively with the Principal Investigator and research team, patient financial services, clinical research billing office, IRB and research compliance related to Medicare coverage analysis issues and determinations.
• Keep current on FDA and Medicare regulations and state laws that apply to clinical trials for research 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 and comprehend complex clinical research protocols, interpret research contracts, study budgets and 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.

Pay Range:

Minimum Annual Salary: $57,510.00

Maximum Annual Salary: $87,697.50

The pay range displayed on this job posting reflects the anticipated range for new hires. A successful candidate’s actual compensation will be determined after taking factors into consideration such as the candidate’s work history, experience, skill set and education. The pay range displayed does not include any applicable pay practices (e.g., shift differentials, overtime, etc.). The pay range does not include the value of Cleveland Clinic’s benefits package (e.g., healthcare, dental and vision benefits, retirement savings account contributions, etc.).