Payment Accuracy Policy Manager, Drugs

Payment Accuracy - Content Policy Manager

Please note: This role requires EST hours and is open to East Coast candidates only.

About Rialtic

Rialtic is an enterprise software platform empowering health insurers and healthcare providers to run their most critical business functions. Founded in 2020 and backed by leading investors including Oak HC/FT, F-Prime Capital, Health Velocity Capital and Noro-Moseley Partners, Rialtic's best-in-class payment accuracy product brings programs in-house and helps health insurance companies gain total control over processes that disparate and misaligned vendors have managed. Currently working with leading healthcare insurers and providers, we are tackling a $1 trillion problem to reduce costs, increase efficiency and improve quality of care. For more information, please visit www.rialtic.io.

This is a new role to drive program management and policy support for clinical edits for hundreds of drugs billed under the medical benefit. 

You will:

• Review healthcare policies and determine the logics to create based on strategic and technical considerations
• Create functional designs and test claims from concept through validation and maintenance
• Review, edit and finalize designs and test claims assigned to content analysts
• Mentor and coach content analysts on conceptualizing, creating and delivering claims processing edits and improving claims processing designs and test claims
• Create and manage special projects and programs from concept through execution and maintenance.
• Troubleshoot edits that do not function as expected and collaborate with Engineering teams to resolve and adjust design and test claims to make edits function as intended.
• Drive prioritization of drug library (partner withour clinical team and go to market teams, plus leverage internal data, to prioritize which drugs will be developed)
• Curating drug edit scoping templates before handing off to the production process
• Partnering with our clinical teams to review & respond to Validation questions
• Identify and create business cases for any system enhancements to support any unique needs for the Drug Edits (partner with Product or Engines to prioritize the enhancements)
• Partner with our Clinical Leadership on providing content development & maintenance, including building the “clinical adherence updates” (aka maintenance) process for managing the covered indications and dosages of each drug. 
• Provide expertise to guide the prioritization and roadmap of edits pertinent to your top knowledge areas
• Develop a Roadmap to guide the creation of your portfolio of claims processing edits
• Perform sampling and validation with client data of beta and in-production claims edits
• This includes:
• Reviewing, interpreting, and creating updates from the review of clinical literature related to the off-label use of drugs. 
• Monitoring and making policy changes in accordance with FDA labels, compendia drug sources, and payer policies.
• Researching new clinical literature and journal articles to identify changes that need to be made to policies.
• Provide policy support for client inquiries on the drug edits

Background/skills required:

• RN or Pharmacist required
• Project Management experience
• Payment Integrity experience
• Oncology experience preferred
• Drug dosing calculation experience
• Experience using Google product suite, including Google sheets preferred

 

Rialtic Values

• High Integrity

• Do the right thing. Provide candid feedback. Be humble and respectful.

• Customer Value Comes First

• Delivering value to our customers is our North Star.

• Work as One Team

• Collaborative, inclusive environment to advance our mission.

• Be Bold & Accountable

• Speak up. Take accountability. Continually improve.

• Pursuit of Excellence

• Innovate, iterate and chase the best possible outcomes.

• Take Care of Yourself & Others

• Prioritize the health and wellbeing of yourself and your teammates.

Rialtic Benefits:

• Freedom to work from wherever you work best and a home office