Payer Policy Advisor

The Payer Policy Analyst analyzes payer policies, interprets complex coding guidance and regulations, and collaborates with cross-functional teams to shape reimbursement pathways for the organization. The Analyst provides insight to help refine appeals, address insurance denials, and influence payer policies to ensure the organization stays abreast of payer policy changes and maximizes its position with external payer partners.

Supports the organization’s adherence to applicable CMS requirements, AMA Official Coding and Reporting Guidelines, government regulations and internal policies. Serves in an advisory capacity to leadership and providers as it relates to documentation, coding, and regulatory compliance.

As a key member of the Coding team, the Payer Policy Analyst:

• Assists organizational leadership to support payer negotiations by providing information on payer policy updates and changes.
• Analyzes coverage data to inform strategic objectives.
• Disseminates payer bulletins and notifications to appropriate departments and leadership.
• Works cross-functionally with teams, including clinical, coding and revenue cycle teams to provide ongoing support on reimbursement policy matters.
• Collaborates with appeals teams to evaluate outcomes, craft compelling rebuttals, and update appeal documentation as needed.
• Conducts policy and coding guidelines searches, leveraging internal resources and external experts to support coverage decisions.
• Stays informed on regulatory developments and policy changes impacting reimbursement.
• Prepares presentations and delivers education sessions to providers, coders, and other members of revenue cycle teams.
• Stays current with Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-10-CM and CPT coding. Completes online education courses and attends mandatory coding workshops and/or seminars (ICD-10 and CPT updates) for Physician Services coding. Reviews AHA and CPT quarterly coding update publications.
• Responsible for working with other departments to respond to coding queries.
• Serves as a subject matter expert on coding/billing topics.
• Performs additional duties to support team goals and company initiatives, as assigned.

EDUCATION AND EXPERIENCE

• 5+ years of experience in a professional coding capacity for orthopedic surgery and Evaluation and Management (E/M) services. Other surgical specialties considered.
• Must have current CPC, COSC, CPMA or CEMC certification from AAPC. Will consider CCS-P or CCS certification from AHIMA, with relevant work experience.
• Associate degree in health information management, health services administration, or related field desired.
• Proficiency in MS Office products - intermediate to advanced knowledge of MS Excel.

SKILLS/ABILITIES

• Ability to consistently and accurately review coding of physician services encounters.
• Ability to create clear and concise feedback reports and maintain productivity standards.
• Strong technical knowledge of Centers for Medicare & Medicaid Services (CMS) regulatory guidelines, including ICD-10 CM, CPT, and HCPCS Procedure Coding, and official coding guidelines.
• Knowledge of disease pathophysiology and drug utilization.
• Knowledge of NCCI edits structure.
• Must be detail oriented and have the ability to work independently.
• Computer knowledge of MS Office, including Word and Excel.
• Must display excellent interpersonal skills.
• Ability to demonstrate initiative and discipline in time management and assignment completion.
• Ability to work in a virtual setting under minimal supervision.