Job Description
Manager, Clinical Content & Reimbursement Location: This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. The Manager, Clinical Content & Reimbursement (Provider Reimbursement Manager) is responsible for driving the development and execution of the clinical content scope in alignment with the product and content strategy to meet financial and operational targets. You'll research and interpret CMS, CPT/AMA and other major payer policies based on medical coding and regulatory requirements. You will identify common error areas that can be made into automated software logic to prevent overpayments from occurring. You will take edits from concept to specification and then through review, testing and finally data validation. Your goal is to develop claims editing logic and content that promote payment accuracy and transparency. How You Will Make an Impact: Leads fee schedule development for specific plan(s) and/or the development and implementation of clinical editing rules. Works with business partners to assist with cost of care claim editing goals. Performs and/or directs complex fee modeling exercises to ensure that projected unit reimbursement changes meet corporate cost targets. Review healthcare policy (Medicaid