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Payment Policy and Reimbursement Analyst

2 months ago

Springfield, United States Health New England Full time
Job DescriptionJob Description

This position is responsible for maintaining and adhering to internal controls, ensuring compliance with applicable laws and regulations, and following Health New England’s entity level policies and procedures. The position is responsible for reporting unethical or fraudulent activity related to business operations and adhering to Health New England’s Code of Conduct.

Summary: Provide a brief summary of the purpose of this role. Include the role’s primary responsibility, its impact on end results, and the degree of freedom to act.

The Payment Policy and Reimbursement Analyst ensures claim payment integrity through the accurate application of industry pricing and coding by internal and external administration of claims editing and pricing of HNE claims as well as supporting the payment policy development and maintenance process. The Payment Policy and Reimbursement Analyst supports HNE cost savings efforts through payment policy and internal initiatives from conception, implementation and savings monitoring as well as issue identification, root cause analysis and resolution for payment integrity related issues.

Essential Functions: List in order of importance the essential duties and responsibilities of this role, and estimate the percentage of time spent on each. Include management and supervisory responsibilities, if any.

Payment Policy Support and Development 50%

  • Lead payment policy development and review through the facilitation of workgroup and committee meetings ensuring all policies are up to date and structured process is followed.
  • Leads cross-departmental introduction, adoption or modification of payment policies as necessary due to regulatory changes, contractual changes, as a result of claims data findings, or internal decision-making.
  • Serve as company’s reimbursement expert regarding payment policies against all lines of business
  • Collaborate with internal departments to define requirements and document those requirements sufficiently to ensure accurate implementation of payment rules within the adjudication system
  • Coordinate other payment policies efforts with other internal initiatives including edit development to ensure payment policies align with current system configuration, medical policy or any member/provider documentation.
  • The Payment Policy and Reimbursement Analyst serves as a resource to HNE providers and internal departments regarding billing issues and appeals specific to payment reimbursement policies and inquiries.
  • Assist contracting and provider relations with communication to providers related to payment policies and methodologies

Cost Savings and Overpayment Recovery Efforts 30%

  • Supports cost savings and overpayment/recovery efforts through data mining, pre-payment solutions, trend analysis, policy research and resolution.
  • Review of reimbursement and overpayments related to payment policies and supporting edits. Supports efforts for new vendor edit or internal/external cost savings initiatives from concept development, research, vetting through data analysis, testing, post prod monitoring, internal communication, edit savings and performance.
  • Supports the claims coding software through analysis of current CCI and CMS changes and appropriate application of rules based processing, and claims pricing through correct application of various industry standard fee schedules through 3rd party vendor pricing.
  • Audits complex hospital and provider contracts compared to claim payment systems in order to confirm appropriate configuration designs and payment policy application
  • Supports troubleshooting of vendor problems, provider appeals and inquiries to identify improvement areas internally through data analytics collaborating closely with all internal stakeholders to prepare solutions and resolve issues presenting to Management as required.

Special Projects 20%

  • Supports management with special projects and any cost savings strategic team efforts to achieve payment integrity goals.


Bachelor’s degree with a minimum of 5 years of related experience and/or training; or an equivalent combination of education and experience.

  • Prior payment policy development required
  • Considerable knowledge of DRG, ICD-10, CPT-4 and HCPCS coding
  • CPC certification preferred
  • Prior health claims adjudication experience preferred
  • Excellent communication skills (both verbal and written), with vendor, client, and internal stakeholders
  • Strong technical writing, critical thinking, problem solving, and conflict management skills
  • Able to handle multiple assignments/responsibilities simultaneously ensuring appropriate organization and prioritization of such responsibilities
  • Math and decision-making skills are important for assisting in the selection of vendors that best fit the company's needs