Medical Policy Specialist jobs in Vermont

JOB DESCRIPTION:

The Payer Compliance and Policy Analyst ("PCPA") maximizes contractual payer compliance and monitors and facilitates risk reduction/mitigation of payer policy changes through detailed analyses of payer agreement policies and procedures related to the managed care agreements with health plans, insurance companies, government payers, and other third party payers for UVMHN, its Affiliates and their affiliated companies. The PCPA performs detailed analyses of all new and revised payer policies (i.e. medical, clinical, payment), and operational procedures to support contracting, operations and billing changes to maximize contractual compliance in an effort to mitigate losses and facilitate UVMHN strategic and budgetary goals.

The PCPA researches and evaluates all relevant state and federal law and statutes to ensure payer policy changes are in compliance with applicable law, ensuring compliance with UVMHN legal, regulatory and compliance policies and state and federal regulation.

The PCPA facilitates identification of payer policy changes that will impact the Affiliates and coordinate a complete analysis of the policy, including but not limited to the following areas; legal, contractual, financial and administrative. In addition, PCPA will identify those policies for implementation by UVMHN Affiliates. For both, the PCPA assists UVMHN Contracting & Payer Relations department supporting Affiliate(s) end-users to ensure payer compliance and proper payer policy implementation; drafts first level dispute to payer policy changes to mitigate loss or impact; drafts and facilitates delivery of annual Agreement notices to payers; drafts and facilitates communication of approved policy changes to Payer Matrix, system configuration, UVMHN Affiliates, and provides initial/concurrent/ongoing educational opportunities for end users.

The PCPA makes appropriate recommendations to improve the operational and financial performance of UVMHN Affiliates, addresses required payer response timelines, and oversees ongoing payer performance and operations maintenance. PCPA will proactively educate Affiliates of payer policy changes for operational effectiveness and efficiencies.

The PCPA maintains reports and summary analyses of compliance monitoring activities, audit data of payer medical policies, drug formularies, and associated procedure coding for Epic configuration/maintenance, monitors and facilitates risk reduction/mitigation of payer policy changes.

Analyses generally include the need to coordinate efforts across multiple Affiliates and departments and third parties; requires excellent communication skills as well as project management skills and results in processes to build, change, or improve contractual relationships and fiscal and operational performance. The PCPA is responsible for establishing and maintaining professional and effective working relationships with the representatives of health plans and insurance companies, UVMHN and Affiliate senior management, health care service leaders, administrative directors, legal staff, patient access, billing departments, clinical departments, Epic managers, internal stakeholders and other external third parties, including regulatory bodies.

EDUCATION:

Bachelor's degree in a health care field or business required; Master's degree in healthcare, J.D. or Paralegal, business administration or other related area preferred; an equivalent combination of education and experience from which comparable knowledge and abilities were acquired may be considered.

EXPERIENCE:

Minimum of two to three years of experience in 1) billing in a complex health care setting with multiple national payer agreements; or 2) compliance or utilization review for a highly regulated industry; or 3) complex medical claim coding in multiple specialties, or 4) statistical analysis experience. The individual must possess significant familiarity with complex healthcare operations, payer performance, payer policy review, payer prior authorization requirements, and Epic functionality.