Claims Policy Data Analyst

Commonwealth Care Alliance - Boston, MA3.5

Full-timeEstimated: $80,000 - $110,000 a year
This is an individual contributor role. Working with the Manager of Reimbursement and Payment Integrity, the Reimbursement Analyst will serve as an internal subject matter expert related to payment policies, payment methodologies, and fee schedules for a wide range of professional, facility, community-based, and behavioral health provider types.

Key Responsibilities
Develop and maintain CCA reimbursement policies and support the payment policy and payment integrity team to ensure that CCA policies remain consistent with the Plan’s adjudication system(s).
Work closely with claims department to ensure that payment policies and methodologies are appropriately implemented and maintained.
Staff and participate in various work groups and committees to support payment policy development and oversight, and provide input into processes and workflows reliant on payment policy outcomes.
Serve as the department’s project manager for: (1) regulatory information such as proposed and final Medicare and/or Medicaid payment regulations, Medicare Manual updates, and CMS fee schedules; and (2) regulatory issues. Determine the scope and impact of the information/issues and take appropriate action.
Serve as the company’s payment/reimbursement expert regarding Medicare, Medicaid, and internally-developed payment policies and methodologies.
Remain current on federal and state payment policies and methodologies; monitor public sources to identify, track, and communicate changes that will affect CCA providers.
Collaborate with stakeholder departments to develop and maintain a centralized location to store payment methodology information.
Develops implementation plans for the introduction, adoption, or modification of payment policies based upon legislative or regulatory actions or internal decision-making.
Assist contracting and provider relations functions with communication to providers related to payment policies and methodologies.
Minimum Qualifications
Bachelor's Degree or equivalent experience.
Preferred educational experience Masters in Business, Public Health, Public Policy, or related field.
Minimum 3 years of experience in health policy and reimbursement or related field.
Experience with health care reimbursement.
Experience with ancillary, long term care, and community-based providers preferred.
Strong health policy analytical skills and familiarity with Medicare and Mass health policies.
Knowledge and experience of health care reimbursement, public health care programs and reimbursement methodologies (Medicaid and Medicare).
Working knowledge of health care reimbursement, claims, and data systems preferred.
Applies subject matter knowledge; requires capacity to understand specific needs or requirements to apply skills/knowledge.
Ability to plan, organize, and manage own work; set priorities and measure performance against established benchmarks.
Comfort working with and communicating new policies.
Ability to communicate and work effectively at multiple levels within the company.
Customer service orientation; positive outlook, self-motivated and able to motivate others.
Strong work ethic; able to solve problems and overcome challenges.
Actively participates in the evaluation of own performance.
Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable).

Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.

CCA is committed to protecting the health of our workforce and our members, and we encourage flu vaccination in accordance with CDC recommendations. Individuals working in clinical care areas or in direct contact with members must provide documentation of flu vaccination, or wear a mask during flu season whenever engaged in member-facing activities.