Payer and Medical Policy Coordinator

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Children's Hospital of Philadelphia (CHOP) offers countless ways to change lives. Our diverse community of more than 20,000 Breakthrough Makers will inspire you to pursue passions, develop expertise, and drive innovation.

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CHOP does not discriminate on the basis of race, color, sex, national origin, religion, or any other legally protected categories in any employment, training, or vendor decisions or programs. CHOP recognizes the critical importance of a workforce rich in varied backgrounds and experiences and engages in ongoing efforts to achieve that through equally varied and non-discriminatory means.

About the Job

The Payer-Medical Policy Coordinator supports the Revenue Integrity team by conducting ongoing payer policy reviews, analyzing and interpreting rules to identify material impacts and ensure accurate billing, coding, and reimbursement. You'll track and report all payer policy activity, act as a liaison between Revenue Integrity, Payment Integrity, hospital departments, and hospital-owned revenue-generating areas to ensure charges comply with payer policy, federal and state regulations while optimizing reimbursement. You'll collaborate with Patient Financial Services to resolve denials tied to billed CPT/HCPCS/revenue codes linked to the CDM. This role includes daily maintenance of assigned work queues, supporting special projects as needed, and partnering across the revenue cycle-PFS, HIM, Case Management, Contracting and Reimbursement Services-so strong communication and the ability to interact effectively across the organization are essential. The ideal candidate is highly detail-oriented and maintains a clear, organized process to catalog all payer policies for easy recall and efficient application. This is an excellent opportunity for someone who thrives in a hospital setting and understands the complexities of payer policies and denial management.

Work Environment & Flexibility

Mostly Remote (Monday-Friday; 8am-5pm) for optimal work-life balance
Onsite requirements: Quarterly onsite meetings with team required at CHOP- to inspire teamwork by bringing the group together to plan boldly, connect meaningfully, and innovate for lasting impact.

Apply today and help strengthen the financial health of our hospital system-while enjoying the flexibility of a remote role.

What you will do

1)Payer Policy Maintenance

• meet with Payer Relations team to communicate findings of payer policy reviews
• monitoring and interpreting payer policies to help ensure accurate billing, coding, reimbursement.
• provide education and training on payer policies
• maintaining compliance with government and commercial payer requirements and minimizing revenue loss due to policy misalignment or denials
• serves as the subject matter expert for payer policy content and interpretation
• prepare reports and presentations for leadership on payer performance and policy impact

2)Coordinate monthly/periodic payer policy updates

• Tracking, trending, documenting all monthly payer policies received from Payer Relations.
• Identify any policy that may have a material impact and communicate to the Payment Integrity team.
• Assess the impact of policy changes on hospital services, including inpatient, outpatient, and ancillary departments.
• Collaborate with clinical, HIM, and billing teams to implement necessary workflow or documentation changes
• Develop educational documents to be presented, shared with the RCO teams Prepare reports and presentations for leadership on payer performance and policy impact
• Develop and maintain a payer policy repository and knowledge base for internal stakeholders

3)New service/New Supply requests

• Works with CDM team, providing insight regarding services/supplies determined to be chargeable or not separately chargeable
• work with Reimbursement Manager in the analysis and determination of charge pricing and changes
• with CDM team for new service/supply requests to help ensure completed requests will be in line with the payer policy interpretations
• Support the implementation of new service lines or care models by evaluating payer policy implications.

4)Responsible for analyzing code denials

• Ensure policies align with federal and state regulations, payer contracts, and organizational goals
• Track and analyze updates to payer policies, including NCDs, LCDs, CCI edits, and commercial payer
• Serve as a subject matter expert on payer policy issues and reimbursement strategies
• Analyze denial trends and reimbursement data to identify payer-specific issues
• Participate in PFS meetings in order to provide feedback on policy issues, denial findings
• Analysis of WQ issues, CDM denials for possible recommendation in relation to payer policy trends

5)Responsible for coordinating periodic update meetings with key stakeholders:

• including Reimbursement, Compliance, PARC Support
• Support contract management teams with policy insights during negotiations
• Help to reduce our compliance risks through studying, reporting and making recommendations relative to on-going and emerging coding compliance issues
• Participates in project team meetings that involve the review of system programs/services relative to thedevelopment of possible changes that impact hospital charge capture or charge entry process
• Serves as the subject matter expert for payer policy content and interpretation
• Prepare reports and presentations for leadership on payer performance and policy impact

Standards for Payer and Medical Policy Coordinator

1)Establishes department standards of excellence.

• Annually, reviews, revises and documents all key departmental processes and develops standards of excellence consistent with the Hospital's mission, values, and quality vision.
• Compares and integrates industry best practices in the department.
• Annually evaluates and measures department's achievement of defined standards of excellence.

2)Establishes integrated systems which improve services and support the Hospital's mission.

• Collects and/or reviews data from customer surveys on specific departmental programs or hospital-wide systems.
• Uses institution-wide surveys to enhance department services on an ongoing basis.
• Annually, participates in and/or contributes to at least one (1) CQI cross-functional and/or departmental quality improvement initiative.

3)Develops, tests, implements and evaluates new and creative approaches to meeting departmental and institutional goals.

• Annually prepares written measurable goals for the department.
• Participates in a work group to improve departmental or cross-functional processes.
• Uses innovative and/or non-traditional approaches to implement changes, which enhance department/institution's ability to meet goals.

4)Integrates trends in healthcare and own profession to forecast future departmental and institutional needs for program development, space, and financial resources.

• Initiates at least one realistic tactical/strategic planning recommendation annually based on trend data and/or benchmarking
• Makes recommendations for technical enhancements (i.e. tools, software, etc.) which will support the department's vision of increased automation of the necessary work-efforts unique to CDM maintenance.

5)Responds promptly and positively to patients, families, associates, and all others in a respectful, courteous and confidential manner.

6)Follows hospital and department procedures and policies, including but not limited to patient safety, mandatory education, confidentiality, attendance, etc.

Licenses and Certifications

• Certified Professional Coder (CPC) - AAPC - upon hire - Required

Education

• Bachelor's Degree - Required
• Bachelor's Degree Clinical Field - Preferred

Experience

• At least five (5) years related professional experience in a hospital patient financial services function - Required
• Experience with coding, billing and CDM maintenance - Required
• At least five (5) years related professional experience in a hospital patient financial services function - Required
• At least three (3) years prior supervisory experience - Preferred
• Clinical experience - Preferred

Required Knowledge, Skills and Abilities

• Experience with coding, billing and policy maintenance
• Strong database and analytic skills; working knowledge of key computer applications such as EPIC and Microsoft Office suite of products
• Ability to promptly recognize, evaluate and manage multiple priorities.
• Excellent organizational skills.
• Ability to function efficiently and professionally with minimum supervision.
• Ability to interact effectively across the organization
• Ability to work independently, achieves specific goals and objectives, and provides recommendations for improvement
• Ability to work collaboratively with a strong orientation for bottom line results.
• Understanding of the local managed care environment, including, but not limited to, managed care policies and procedures, payment models and managed care models.

To carry out its mission, CHOP is committed to supporting the health of our patients, families, workforce, and global community. As a condition of employment, CHOP employees who work in patient care buildings or who have patient facing responsibilities must receive an annual influenza vaccine. Learn more.

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SALARY RANGE:

Salary ranges are shown for full-time jobs. If you're working part-time, your pay will be adjusted accordingly.

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At CHOP, we are committed to fair and transparent pay practices. Factors such as skills and experience could result in an offer above the salary range noted in this job posting. Click here for more information regarding CHOP's Compensation and Benefits.