Senior Reimbursement Policy Consultant - CPC

Position Description

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. 

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

The Senior Policy and Reimbursement Consultant is required to integrate the implications of coverage and benefit issues, medical necessity, current industry practices, provider contracts, state and federal mandates, other regulatory requirements, corporate policies, and internal business system constraints in the analysis and development of Network Policy and application of correct coding. The Consultant takes a leadership role in the research, development, communication, and documentation of Provider Reimbursement Policy and acts as a liaison from the Corporate Coding unit to a variety of interdepartmental project teams as assigned. The Consultant functions as a lead member of a multidisciplinary team responsible for the configuration and communication of Network Policies and correct coding. The Consultant supports the Network Policy Unit and cross functional units through the research, analysis, development, documentation and maintenance of correct CPT, HCPCS, ICD-9, ICD-10 and Place of Service codes, and serves as a subject matter expert on provider reimbursement methodology.

Responsibilities and Qualifications

• Serve as SME in the implementation process for the timely communication and configuration of new and/or revised reimbursement policies in the payment system.
• Serve as SME in coding and reimbursement methodology to the Provider Appeals Committee.
• Provide training to others in Corporate Coding Units and other areas of CBC that may require training. May include development of training materials and scenarios for use in training exercises.
• Reviews and analyzes newly released HCPCS, CPT, ICD-9, ICD-10 codes as well as Modifiers and Place of Service codes for impact to providers. Reviews and analyzes Claims Editing Software (CES) documents to identify impact to providers.
• Responsible for the annual review of existing and development of new Reimbursement Policies/Methodologies to include: Data analysis, Revisions to policy language, Creation of new policy language, Code list in support of policies, Recommendation including options, pros and cons, Determine need for and draft Provider Communication language, Review test results to validate system configuration in support of policy.
• Respond in a timely manner to questions pertaining to claims processing, correct coding application and provider reimbursement as needed.

Skills:

• Demonstrated statistical, analytical and research skills paired with a demonstrated ability to identify the root cause of business and operational issues and develop and implement processes to address.
• Demonstrated ability to work independently and adjust to changing priorities to manage time effectively and meet urgent deadlines.
• Demonstrated ability to communicate effectively, both in writing and verbally, with individuals of diverse background and knowledge within the company.
• Demonstrated ability to interpret healthcare data and reports and clearly communicate complex data relationships in support of existing or proposed reimbursement methodologies and issues, both verbally and in writing, both from the technical perspective and using clear non-technical language, to all levels of internal and external customers.
• Demonstrated ability to quickly gain knowledge of new business processes and issues.
• Demonstrated ability to establish and maintain cooperative working relationships across multiple departments within Capital BlueCross.

Knowledge:

• Provider reimbursement strategies including industry standards, competitor approaches, and professional and facility society opinions.
• Medical practice for professional and/or facility providers, medical terminology, ICD-9-CM, ICD-10-CM, CPT, HCPCS and NDC coding structures.
• Understanding of Capital’s products, performance measurement processes