Payment Policy Analyst - Clinical

Job Description

Use Your Strengths at Wellmark as a Payment Policy Analyst - Clinical! 

The Payment Policy Analyst plays a critical role within our Payment Integrity team, helping ensure provider claims are paid accurately, efficiently, and in accordance with payment policies. In this role, you’ll review provider payment inquiries, claims, medical records, and supporting documentation to identify trends, investigate inconsistencies, and understand not only what happened with a claim, but why. You’ll apply your knowledge of claims, coding, and medical terminology to research complex issues, develop well-supported recommendations, and translate detailed clinical information into clear, actionable insights. You’ll collaborate with Payment Integrity partners, Medical Directors, Medical Policy, and other stakeholders to enhance payment policies and processes. 

Ideal candidates are naturally curious, analytical, and detail-oriented problem solvers who enjoy digging into complex questions and looking beyond the first answer. You’re comfortable asking questions, challenging assumptions, and escalating concerns when appropriate, and you use credible sources to reach thoughtful conclusions. You’re highly collaborative, enjoy working as part of a team, and can adapt quickly as priorities, processes, and business needs evolve. You’re a lifelong learner and consistently aim to learn. Varied clinical experience is a must. Claims and/or coding knowledge will help you succeed, particularly when reviewing complex medical records and interpreting diagnosis codes, modifiers, and other claim information.  

Hybrid environment: This position will work a hybrid schedule of at least 3 days (Tuesday, Wednesday, Thursday) in Wellmark's Des Moines office, with 2 days (Monday, Friday) remote option.   

Qualifications

Required Qualifications:

• -Associate degree or direct and applicable work experience.
• -Either an Active and Unrestricted Licensed Practical Nurse (LPN) in Iowa or South Dakota (individual must be licensed in the state in which they reside) OR an Active and Unrestricted Registered Nurse (RN) license in Iowa or South Dakota (individual must be licensed in the state in which they reside).
• -Coding certification – e.g., CPC, CPC-P, COC, CCS-P, RHIT, or RHIA, or the ability to obtain a certification within 6 months of hire.
• -Ability to identify issues or inconsistencies; obtains relevant information, relates and compares data from different sources and identifies alternative solutions.
• -Understanding of regulatory standards, accreditation standards, or guidelines including interpretation of technical specifications for data file and system upgrades.
• -Demonstrated ability to communicate effectively and professionally, verbally and in writing, expressing complex concepts clearly and concisely to various levels of audiences.
• -Demonstrated critical thinking, problem solving/troubleshooting, research, and continuous process improvement skills with the ability to interpret medical policies/procedures and apply analytical and technical knowledge in order to develop and communicate recommendations to stakeholders for solutions.
• -Self-starter with effective time management skills and the ability to organize and prioritize competing projects or tasks. Flexible and adaptable to change.
• -Proficiency with Microsoft Office-e.g., Outlook, Word, Excel. Technical aptitude to learn new software quickly.
• -Ability to work independently and cooperatively on teams, maintaining positive relationships with customers.
• -Interest in coaching/mentoring others.
• -Proficiency in HROR preferred.

Additional Information

What you will do:

a. Responsible for the research, analysis, development, maintenance, coordination, and documentation of payment policies. Using standard, established sources, the Internet, and relevant peer-reviewed articles, interpret and summarize findings of the research, including demographic, statistical and scientific information.

b. Monitor healthcare trends, industry publications and statewide regulations to provide education and potential payment policy recommendations.

c. Review and scrutinize provider payment claim reports on a daily basis. Review for reasonableness and monitor claims trends. Ensure claims are being paid accurately and efficiently, according to payment policies. Proactively identify and document questionable activity and work with others toward resolution.

d. In collaboration with payment policy vendor, work to enhance the claims payment process and contribute to the achievement of Wellmark’s benefit savings goal. Collaborate and work directly with the provider community, Network Engagement Business Partners, Medical Directors and other Wellmark stakeholders to develop and enhance provider payment policies.

e. Accountable for researching, analyzing, monitoring, and updating the resolution of high complexity claims, contracting and provider inquires.

f. Ensure coding files are updated as required by code set revisions, HIPAA-AS, medical policy development and implementation, regulatory requirements, FEP and Blue Card guidelines, or as needed to support other internal processes.

g. Support others and provide business expertise for system conversions and release upgrades. Provide implementation support and editing process documentation.

h. Other duties as assigned.  

An Equal Opportunity Employer

The policy of Wellmark Blue Cross Blue Shield is to recruit, hire, train and promote individuals in all job classifications without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or any other characteristic protected by law.

Applicants requiring a reasonable accommodation due to a disability at any stage of the employment application process should contact us at [email protected]

Please inform us if you meet the definition of a "Covered DoD official".

At this time, Wellmark is not considering applicants for this position that require any type of immigration sponsorship (additional work authorization or permanent work authorization) now or in the future to work in the United States. This includes, but IS NOT LIMITED TO: F1-OPT, F1-CPT, H-1B, TN, L-1, J-1, etc. For additional information around work authorization needs please refer to the following resources:Nonimmigrant Workers and Green Card for Employment-Based Immigrants 

Wellmark supports and expects the responsible use of AI for our workforce! We welcome the responsible use of these tools by job seekers as well and are interested in learning from you; you will have an opportunity in the application process to share which tools you used and how you applied them.