Program Management Senior Advisor - Healthcare - Remote

Program Management Senior Advisor, Payment Policy and Coding Business Implementation Lead (BIL)

The Program Management Senior Advisor (Band 4, Individual Contributor) is a senior operational leader responsible for ensuring the accurate, compliant, and high-quality execution of regulatory driven alignment across reimbursement rules, prior authorization, and medical policy implementation. This role translates complex regulatory, legal, and policy requirements into disciplined execution, bringing structure to ambiguity and driving coordinated delivery across highly matrixed, cross functional teams.

As the Business Implementation Lead (BIL) of the Payment Policy and Coding team (PPC) you will act as the point person within the PPC business segment responsible for managing and coordinating the implementation process to ensure compliance of coverage, reimbursement, administrative, and code editing policy. This position is responsible for driving awareness, assessment and implementation of new federal and state laws, which includes reviewing impacts of new and revised compliance instructions and mandates and how it translates to policy implementation.

The BIL will work cross functionally with affordability implementation partners and within the PPC along with other BILs as necessary and maintain a close partnership with Regulatory and Compliance teams.

Additional principal functions of this role include:

• Providing compliance awareness and project management support for the Payment Integrity organization.
• Developing quarterly compliance reports for the leadership team.
• List management and process improvement of biomarker coding
• Affordability Project Compliance support – 50 state compliance review to evaluate project impacts and compliance risk tied to editing
• Preventive Workgroup and Committee compliance alignment and consultation support
• Partner with various clinical leads as necessary to address policy related compliance matters
• Partner with the enterprise Legal/ Compliance organization as needed for PPC compliance matters.

This role requires a great level of autonomy, independent critical thinking and flexibility to drive creative approaches and solutions to root cause analysis and problem solving, employing a wide range of methods, tools, and techniques to achieve optimal cross functional efficiencies and the strategic objectives of the PPC. Responsibilities include leading and delivering on cross operational initiatives, clinical governance analysis and operational work stream(s) support.

This position will drive development and maintenance of compliance implementation action plans, outcomes and tracking/reporting with the ability to monitor progress against goals, timely escalation of barriers to success along with identification of potential solutions.

Key

Duties and Responsibilities:

• Review weekly Regulatory Instructions (RIs), assess applicability and impact across Payment Integrity (PI) and Payment Policy and Coding (PPC), and identify questions, risks, or implementation considerations for discussion with Regulatory and Compliance partners.
• Participate in weekly Law Forum and Implementation Forum discussions; engage the State Regulatory Manager, Compliance Manager, New Law Implementation Lead, and other partners to support timely interpretation, planning, and execution of regulatory requirements.
• Lead coordination of cross-functional implementation activities by identifying appropriate SMEs, aligning impacted teams, and partnering with other BILs when new laws create cross-business dependencies or sequencing considerations.
• Develop, manage, and track implementation action plans, deliverables, timelines, controls, and evidence of compliance, including documentation in Open Pages where RI records are maintained.
• Identify barriers to implementation, evaluate alternative solutions, escalate risks or issues as appropriate, and provide ongoing communication to ensure obstacles are addressed and required support is in place.
• Coordinate compliance-related requirements and deliverables across applicable implementation vehicles, including Claims Xten, Prepay, Precertification, Pricing, benefit classing, claim…