Dir Claims Editing/Policy

The Director of Claims Editing and Policy is a thought-leader overseeing the development, implementation, and maintenance of policies and processes related to claims editing and reimbursement to ensure accurate claims processing and compliance with regulatory and business requirements. This role requires collaboration with cross-functional teams to ensure safeguards against Fraud, Waste, and Abuse (FWA). This role is is a key figure in ensuring accurate and efficient claims processing and reimbursement and plays a crucial role in optimizing payment accuracy, compliance, and provider satisfaction.

Key Responsibilities

• Review, design and implement claim editing rules and procedures that ensure accuracy, compliance with regulations (like CMS and AMA guidelines), and efficient claim processing.
• Leverage claim editing software to automate and streamline the process. Claims editing often relies on sophisticated software and systems. The director would be responsible for assisting with the selection, implementation, and maintenance of these technologies to ensure optimal performance and accuracy.
• Partner to establish and oversee the organization's claims reimbursement policies.
• Ensuring adherence to all applicable regulations, including those related to healthcare coding, billing, and reimbursement, is crucial. This would involve staying abreast of changes in regulations and implementing necessary updates to policies and procedures.
• Oversee the analysis of claims data to identify trends, areas for improvement, and potential issues related to coding, billing, and reimbursement. This would involve using data to inform policy adjustments and improve overall efficiency
  and accuracy.
• Collaborate with stakeholders, including medical management, claims, network, and compliance, to evaluate policy and editing recommendations.

Education:

• Bachelor’s degree in Healthcare Administration, Information Systems, Business, or a related field (or equivalent experience).

Experience:

• 5 years hand-on experience in defining, customizing and implementing claims editing related to first and second pass editing.
• 3 years of experience in claims processing, payment integrity, and/or reimbursement policy.
• Deep knowledge of coding standards, reimbursement policies, and healthcare data analytics.

Skills and Competencies:

• Excellent analytical, problem-solving, and interpersonal skills.
• Strong understanding of Payment Integrity first and second pass claims editing systems including edit content development.
• Proven ability to influence reimbursement policies to promote payment accuracy.
• Strong understanding of healthcare reimbursement regulations and policies.
• Excellent communication and interpersonal skills to work effectively with various stakeholders.
• Ability to manage multiple priorities in a fast-paced environment.

Preferred:

• • Knowledge of Optum Claims Editing System (CES)
  • Certification in medical coding (e.g., CPC, CPB).

Work Environment

• Hybrid or remote work options available.
• Collaborative team environment with opportunities for professional growth.