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Coverage Analyst

3 months ago

Houston, United States Houston Methodist Full time

At Houston Methodist, the Coverage Analyst position is responsible for reviewing clinical research protocols, informed consent forms, clinical trial agreements, and other relevant study-related documents. The position determines whether proposed clinical research studies are a qualifying clinical trial as defined by the Medicare Clinical Trial Policy (NCD 310.1), while also being cognizant of Medicare/Medicaid Benefit Policies, third-party Medical Benefit Policies, relevant National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), Code of Federal Regulations (CFRs), state laws, professional practice guidelines, and claims denial report, and when necessary, will consult with the Medicare Administrative Contractor (MAC) for the region.

The position will assist with creating a billing justification plan or 'coverage analyses' to reflect which medical procedures and services may be 'Routine Cost' and billable to patient insurance and which ones are research and paid by the study sponsor. This position will develop coverage analysis or billing risk analysis on investigator-initiated, industry-sponsored, and non-industry sponsored clinical trials across multiple disciplines and clinical conditions. The Sr Coverage Analyst position collaborates with Principal Investigators (PI's), Central Business Office (CBO), project managers, study coordinators, investigational pharmacists, and other research and administrative staff to further develop coverage analysis billing plans and confirm current procedural codes (CPT) and Healthcare Common Procedure Coding System (HCPCS) and non-coded services (e.g., study team effort and supplies. This position integrates diverse elements of clinical trial management and requires creativity, teamwork, and collegiality to develop and maintain sound fiscal and administrative systems. The Sr Coverage Analyst position ensures institutional research billing compliance with all applicable federal, state, and local laws, rules, regulations and policies and institutional policies and standard operating procedures.

PEOPLE ESSENTIAL FUNCTIONS Effectively communicates and interacts with various research personnel to include Principal Investigators (PI's), Clinical Trial Managers, Research Coordinators, Billers/Coders, and Internal Audit. Collaborates with PI's and clinical research teams to review Schedule of Events, Protocol, clinical trial agreement (CTA) and create a Coverage Analysis. Collaborates with CBO to confirm procedural codes, CPT and HCPCS, for medical procedures and services, as needed. Conducts self in a manner that is congruent with cultural diversity, equity and inclusion principles. Provides contributions towards improvement of department scores for employee engagement, i.e., peer-to-peer accountability.

SERVICE ESSENTIAL FUNCTIONS Work closely with PI's and research staff to ensure research patient care costs are identified and consistent with clinical research protocols, informed consent, and CTA. Effectively communicates results of coverage analysis to research team and clinical department personnel to ensure understanding of Medicare NCD, LCDs and related billing regulations associated with research patient care costs vs. routine care.

QUALITY/SAFETY ESSENTIAL FUNCTIONS Adheres to institutional research billing compliance with all applicable federal, state, and local laws, rules, regulations and policies and institutional policies and standard operating procedures. Reviews clinical trial documents for the nature of the study and every medical procedure/service to be provided to determine if the study is a qualified clinical trial pursuant to CMS National Coverage Determination 310.1 (the Medicare Clinical Trial Policy) or otherwise approved by CMS.

FINANCE ESSENTIAL FUNCTIONS Develops a Coverage Analysis on clinical trials based on CMS and other third-party payors rules and regulations to identify covered vs noncovered items and services associated with an Institutional Review Board (IRB) approved study. Competently interprets financial requirements within clinical protocols, consent forms, research contracts and budgets to perform a comprehensive MCA to ensure accurate determinations of research patient care billing.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

Periodically reviews services and items associated with an IRB study to determine if insurance reimbursed for services rendered. Effectively work with various computer programs needed to perform assigned tasks such as EPIC, OnCore, MORTI, Excel. Seeks opportunities to identify self-development needs and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates My Development plan on an on-going basis.

This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises. EDUCATION Bachelor's degree in business, Hospital/Healthcare Administration, Nursing or a related field

WORK EXPERIENCE Three years relevant experience in clinical research or billing compliance in healthcare, preferably in a research setting

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