Policy Manager

The Opportunity:

The Payment Policy Manager is vital to the team and responsible for developing, implementing, and managing payment policies and strategies by analyzing regulatory changes and reimbursement models to optimize revenue and ensure compliance with federal, state, and payer-specific guidelines.

This role complements the writer of the claims by setting up our Claims editing process in the Claims editing software system and responding to business needs.

This role works closely with clinical, financial, and revenue cycle teams to interpret payment policies and provide guidance on reimbursement practices that impact the organization's financial performance.

• Evaluate current Claims Xten/CCI configuration in collaboration with IT Configuration, the Data Steward, Claims staff and key stakeholders, ensuring that Claims Xten configuration aligns with the approved business requirements and payment policies.
• Lead and contribute to business discussions re: coding, configuration and claim adjudication, drawing on claims experience, knowledge of regulatory requirements, industry standards re: coding and billing and payer benchmarking for ad hoc and system-wide decisions.
• Support the maintenance and enhancement of Claims Xten/CCI information/documentation in Claim Editing Repository.
• Research projects and create written documentation as it relates to medical billing and coding rules and All Ways Health Partners' provider payment guidelines (PPGs).
• Regularly monitor changes in CMS coding regulations, state regulations and AMA guidelines and understand how these changes impact All Ways Health Partners' PPGs. Research and develop clear documentation of CMS's semi‑annual update of code changes to support the Benefit & Coding Committee review process.
• Create reports and publish recommendations to the Provider Network Management leadership team on coding rules and provider payment policies to allow for informed operational and financial decisions, based on these results.
• Draft new and revised written provider payment guidelines based on decisions made by PNM leadership team, fee schedule methodology projects and decisions made by the Benefit & Coding Committee. Coordinate edit review of new and revised PPGs based on feedback received from Provider Payment Guideline Committee members.
• Coordinate the publishing of PPGs on All Ways Health Partners .org with Corporate Communications, within the timelines created by PNM service standards. Additionally, coordinate the distribution of finalized PPGs to impacted departments with any required supporting documents.
• Participate in cross‑functional teams and present research findings on medical coding and PPG issues to PNM Leadership team, the Provider Payment Guideline Committee and the Benefit & Coding Committee.
• Represent Reimbursement Strategy as a subject matter expert on corporate projects, committees or work groups.
• Provide technical business summaries on claim editing topics in support of work required to develop and maintain business documentation.
• Provide research and benchmarking on codes and claim edits represented by governmental and other regulatory agencies, as released quarterly; lead the code load process, including business requirements submission to IT Configuration.
• Lead Claims Xten and coding discussions on operational work and selected projects; work with colleagues from key areas including: IT Configuration, Claims, Compliance, Benefits Administration, Provider Payment Integrity and, Customer Service.
• Monitor the accuracy of Claims Xten documentation by monitoring and editing software as needed, reviewing online materials and by working with internal stakeholders as needed.
• Evaluate the Claims Xten/CCI edits Library to identify and prioritize updates for QNXT, Claims Xten, CCI and wizards.
• Lead Claims Xten meetings and other meetings as assigned.

• Bachelor's Degree required
• Certified Professional Coder (CPC) highly preferred
• Can this role consider or review experience in lieu of a degree? No

• At least 5-7 years of experience in payment policy management, managed care, reimbursement strategy, or healthcare…