Commonwealth Care Alliance is a rapidly growing nonprofit organization providing integrated health care and social support services to people with complex medical needs. Our patients are seniors and persons with disabilities covered under Medicaid or both Medicaid and Medicare. Our innovative care model is nationally recognized for its effectiveness in improving health outcomes for these vulnerable populations.
Our unique care model is empowering for our employees as well as our members. Whether you are a clinical or administrative professional, all of us at Commonwealth Care Alliance receive the satisfaction of knowing our work truly makes a difference. We enjoy a company culture of passionate advocacy in a supportive work environment with opportunities for growth and learning, competitive salaries, and a generous and comprehensive benefit package.
This is an individual contributor role. Working with the Director of Claims Manager of Reimbursement, the Reimbursement Analyst will serve as an internal subject matter expert related to payment policies, payment methodologies, and fee schedules for a wide range of professional, facility, community-based, and behavioral health provider types.
• Develop and maintain CCA reimbursement policies and support the payment policy and payment integrity team to ensure that CCA policies remain consistent with the Plan’s adjudication system(s).
• Work closely with claims department to ensure that payment policies and methodologies are appropriately implemented and maintained
• Staff and participate in various work groups and committees to support payment policy development and oversight, and provide input into processes and workflows reliant on payment policy outcomes.
• Serve as the department’s project manager for: (1) regulatory information such as proposed and final Medicare and/or Medicaid payment regulations, Medicare Manual updates, and CMS fee schedules; and (2) regulatory issues. Determine the scope and impact of the information/issues and take appropriate action.
• Serve as the company’s payment/reimbursement expert regarding Medicare, Medicaid, and internally-developed payment policies and methodologies.
• Remain current on federal and state payment policies and methodologies; monitor public sources to identify, track, and communicate changes that will affect CCA providers
• Collaborate with stakeholder departments to develop and maintain a centralized location to store payment methodology information.
• Develops implementation plans for the introduction, adoption, or modification of payment policies based upon legislative or regulatory actions or internal decision-making
• Assist contracting and provider relations functions with communication to providers related to payment policies and methodologies
Minimum Education Required Bachelor's Degree or equivalent experience.
• Ideally would like candidate to have CPC Certification
• Minimum 3 years of experience in health policy and reimbursement or related field
• Experience with health care reimbursement
• Experience with ancillary, long term care, and community-based providers preferred
• Strong health policy analytical skills and familiarity with Medicare and Mass health policies.
• Knowledge and experience of health care reimbursement, public health care programs and reimbursement methodologies (Medicaid and Medicare)