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The Payment Policy Program Manager will be responsible for developing, implementing, and managing system edits, payment policies and programs that ensure compliance with regulatory requirements and support the company's strategic objectives. This role requires a deep understanding of healthcare payment systems, regulatory environments, and the ability to collaborate with cross-functional teams to drive policy initiatives.

MINIMUM QUALIFICATIONS :

EDUCATION, EXPERIENCE, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s Degree in a related field or the equivalent combination of training and experience AND Five (5) years in claims processing, payment policy, or claims editing management related experience

OR

High school diploma or equivalent AND Eight (8) years in claims processing, payment policy, or claims editing management related experience

2. Certification in one of the following: RHIT (Registered Health Information Technician), RHIA (Registered Health Information Administrator), COC (Certified Outpatient Coder), CCS (Certified Coding Specialist), or CPC (Certified Procedural Coder).

PREFERRED QUALIFICATIONS :

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Certified Professional Coder (CPC)

EXPERIENCE:

1. Medical chart review/auditing

2. Knowledge of Medicare, Medicaid, and Commercial coding rules and regulatory requirements

3. Experience using EPIC Tapestry

4. Extensive background of ICD-10 and CPT coding procedures, as well as knowledge in medical claim editing

5. Experience working with industry standard methods of payments (percent of charge, DRG, etc.)

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Manage, review, and maintain the CES edit library.

2. Develop and maintain payment policies relating to claim edits.

3. Lead and participate in workgroups to review proposed changes or new edits and the impact on applicable departments.

4. Monitor and analyze changes in healthcare regulations and payment systems to ensure compliance and identify opportunities for improvement.

5. Provide documentation to internal departments to assist in provider education.

6. Fields and responds provider inquiries, including payment disputes, resulting from Payment Integrity activities.

7. Track and analyze edit data to gain insights and create efficiencies.

8. Manage vendor relationships.

9. Provide guidance and training to internal teams on payment policy changes and their implications.

10. Conduct regular audits and reviews of payment policies to ensure ongoing compliance and effectiveness.

11. Prepare and present reports on payment policy initiatives and outcomes to senior management.

12. Represent the company in industry forums and regulatory meetings related to payment policies.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Sitting and working on a computer for several hours a day

2. Must have visual and hearing acuity within the normal range.

3. Must have manual dexterity needed to operate computer and office equipment.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment

2. Visual strain may be encountered in viewing computer screens, spreadsheets, and other written material.

SKILLS AND ABILITIES:

1. Proficiency in coding and industry standards such as Medicare, Medicaid, and Commercial regulations

2. Strong communication skills (both oral and written) skills, organizational skills, and ability to work with other departments and/or outside vendors

3. Knowledge of Optum CES product, or experience using similar claims editing systems

4. Expertise utilizing Microsoft Office products

5. Excellent written and oral communication with internal and external partners

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

541 PHH Accounting