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Professional - Non-Clinical
Reimbursement Policy Analyst III
Houston, TX, US
We’re looking for a Reimbursement Policy Analyst III, someone who’s ready to grow with our company. In this position you will support and develop programs aligned with Health Plan strategic goals through effective and timely leading the development, planning, and implementation of new or current medical coding reimbursement policies leveraging medical coding certification and billing reconciliation experience. Conducts financial impact analysis based on claim utilization based on changes to reimbursement policy, MCO notices, Bulletins, and applicable regulatory guidelines (CMS /
HHSC / TMPPM / CHIP). Recommends optimal system configuration based on medical coding billing / reimbursement experience. Leads medical policy meetings and participates in policy discussion by providing comments and recommendations orally or in writing.
Think you’ve got what it takes?
Job Duties & Responsibilities
• Researches, analyzes, and creates health plan reimbursement policy leveraging medical coding certification and billing experience that includes analyzing the regulatory guidelines and converting to creation of medical policy and financial impact analysis.
• Researching & analyzing medical policy and procedures, assessing risks and its impact to dependent areas and providing system optimization recommendation.
• Analyzing and evaluating complex federal and state legislation and creation of financial impact analysis.
• Create technical & non-technical documentation.
• Provide leadership oversight and participation on Medical Expense Review committee on remediation of expense variations as it relates to alignment to regulatory requirements and possible system impacts.
• Applies reimbursement, regulatory, payment integrity, and systems functional knowledge to ensure regulatory adherence for provider reimbursement.
• Research, develop, and implement a coordinated approach to ensure regulatory adherence for the department, through participation in Medical Policy, Reimbursement Committee, Compliance, and other workgroups as needed, provides support for the facilitation of the process and/or system changes.
• Lead the development & implementation of quality processes and procedures in accordance with applicable standards.
• Lead and coordination weekly Payment Operations calls for review of weekly compliance notifications. Provide mentorship and coaching on the interpretation and conversion to system configuration
Skills & Requirements
• Required bachelor's degree
• Required 5 years billing experience, claims processing, and/or configuration of benefits/contracts/fee schedules/medical policy payment rules
• Preferred 3 years Healthcare industry or MCO environment
• Preferred 3 years Contract / Benefit Engine for Tapestry Certification and 3 years Interpreting complex contract language and intent specific to provider reimbursement
• Preferred CMC CODE - Cert-Certified Medical Coder
• Preferred Project Manager Certification
• Nine (9) years billing experience, claims processing, and/or configuration experience can substitute a bachelor's degree
About Texas Children’s
Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.
To join our community of 15,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities.
Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
