Research Medicare Coverage Analysis Specialist

ccf; United States; Hybrid; USD 85,000 - 110,000; Full time

Job summary

Cleveland Clinic Health System is seeking a Research Medicare Coverage Analysis Specialist to determine qualifying clinical trial status and perform detailed coverage analyses per NCD 310.1 and the Federal Clinical Trials Policy.

You will review protocols, regulatory documents, and budgets to ensure compliant billing and accurate CPT coding. The role supports building the centralized MCA Office and requires collaboration with investigators and billing offices.

Qualifications

• Bachelor's degree or six years of relevant experience in research billing, compliance, or sponsored clinical trials.
• Excellent written and oral communication with multiple stakeholders.
• Ability to interpret complex clinical research protocols, contracts, budgets, and consent forms.
• Ability to manage high-volume workload and meet deadlines.

Responsibilities

• Determine qualifying clinical trial status and perform detailed coverage analyses per NCD 310.1 and Federal Clinical Trials Policy.
• Review protocols, regulatory documents, informed consent, FDA/CMS documents, and budgets to assess patient care items.
• Apply policies from federal/state CMS guidelines and professional practice guidelines for coverage determinations.
• Document coverage justification with cited resources for determinations.
• Assist in claims review and apply CDM/CPT codes for billable items, identifying charges to sponsors.
• Collaborate with Principal Investigator, research team, patient financial services, and compliance offices on determinations.
• Stay current on FDA and Medicare regulations and state laws affecting clinical trials.
• Develop tools and billing grids for Medicare Coverage Analysis processes.
• Other duties as assigned.

Skills

Healthcare administration

Effective communication

Policy interpretation

Time management

Education

Bachelor's degree in Healthcare Administration, Medical Coding, Auditing, Finance, Accounting, Nursing or related field

Six years of relevant experience in lieu of degree

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.

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.

This position is part of a brand-new department at the Cleveland Clinic and offers the opportunity to work as a team member providing Medicare Coverage Analysis for a variety of research projects across the enterprise. The role will establish the centralized MCA Office to ensure billing compliance, protect the organization and patients, and improve operational efficiency. This role is critical to achieving these goals, standardizing processes, and safeguarding Cleveland Clinic's reputation and financial stability. It is also essential to mitigate the risks of improper billing in clinical trials, which can lead to significant fines, penalties, reputational damage, and exclusion from federal programs.

We have four openings for this position.

A caregiver in this position works a hybrid schedule from 8:00 a.m. - 5:00 p.m.

To be considered for this role, caregivers must reside in Ohio, Florida or Nevada.

A caregiver who excels in this role will:

• Responsible for making determinations of qualifying clinical trial status and performing 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, any 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 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 and four years of relevant experience in research billing, compliance, and/or direct involvement with sponsored clinical trials.
• In lieu of degree, six years of relevant experience in research billing, compliance, and/or direct involvement with sponsored clinical trials.
• Excellent oral and written communication skills and the ability to effectively communicate with the Principal Investigator, research team, central offices and study Sponsor.
• Ability to interpret and comprehend complex clinical research protocols, interpret research contracts, study budgets and consent forms to extrapolate billing/coverage data.
• Ability to manage high volume workload and meet required deadlines.