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Medical Policy And Pricing Advisor

Company

Karna
Address , Remote
Employment type FULL_TIME
Salary
Expires 2023-07-21
Posted at 11 months ago
Job Description
Overview:
This position is for a senior Medical Policy and Pricing Advisor on the World Trade Center (WTC) Health Program. The advisor will be responsible for developing medical audits, recommending policy changes, and providing expertise on pricing methodologies.
Responsibilities:
  • Responds to medical claims appeals.
  • Creates a quarterly FECA fee schedule and recommends annual rates for roll-up codes for Monitoring and Survivor Screening visits.
  • Works with the Provider Relations Team to answer provider questions on policy and pricing issues.
  • Updates and maintains a pricing calculator for FECA rates by zip code.
  • Conducts ad hoc research for the internal team and the client.
  • Develops pricing recommendations for unlisted, miscellaneous, and unpriced codes using FECA, CMS, and other fee schedules.
  • Conducts medical utilization audits to ensure quality control.
  • Provides training to the client and other stakeholders on proper medical claims billing, pricing methodologies and Program policies and procedures.
  • Conducts policy and pricing research on other Federal payors, including CMS, Tricare, Veterans Affairs (VA), and the Office of Workers’ Compensation Programs (OWCP).
  • Provides expertise on pricing methodologies, including the Federal Employees’ Compensation Act (FECA), Diagnosis Related Groups (DRGs), Cost to Charge Ratio (CCR), the Outpatient Prospective Payment System (OPPS), Centers for Medicare and Medicaid Services (CMS) PPS Exempt Cancer Hospitals, and other PPS methodologies.
  • Provides recommendations to the client on health care policy and procedure development.
Qualifications:
  • Expert knowledge of CMS and other Federal claims processing rules, regulations and policies in areas such as long term care and durable medical equipment (DME)
  • Experience working in limited care healthcare programs preferred
  • Experience in developing medical policies and procedures
  • Knowledge of MicroStrategy preferred
  • Experience in running or working in a healthcare program in compliance with Federal law and regulations
  • Ability to work in a team and independently
  • Comprehensive knowledge of medical, administrative, ethical, and legal requirements related to healthcare delivery and privacy of protected patient information
  • Bachelor's degree
  • Strong analytical and problem solving skills
  • Experience with Quality Assurance review of medical claims and systems
  • Ability to obtain and maintain appropriate clearance
  • Five or more years of work experience in healthcare administration
  • Proficient in Microsoft Excel
  • Must be familiar with coding systems including ICD, CPT, HCPCS and DRG
  • Expert knowledge of Federal fee schedules, including FECA, DRG, CCR, CMS PPS-ExemptCancer Hospitals, and OPPS
  • Strong verbal and written communication skills
PM18