IBR Policy and Content Development Analyst

Accountabilities:

Develop and maintain audit concepts: Review, update, and enhance existing audit concepts according to established review schedules and in response to client requirements, regulatory changes, and evolving coding standards.
Research regulatory and coding requirements: Analyze changes in healthcare regulations, medical coding guidelines, reimbursement methodologies, and payer policies to assess their impact on existing audit concepts and document findings clearly.
Apply client-specific policies: Interpret and incorporate payer-specific reimbursement rules, medical necessity criteria, and contractual requirements into audit concept reviews and updates.
Interpret government and regional policies: Research and apply state-specific Medicare and Medicaid provider manuals, regional regulatory requirements, and applicable government payment guidelines to audit configurations.
Identify new audit opportunities: Evaluate payer policies and claims trends to identify coverage gaps, reimbursement inconsistencies, and opportunities to propose new audit concepts to clients.
Support multiple payment programs: Ensure audit concepts are appropriately developed and maintained across Medicaid, Medicare, and commercial insurance programs, taking into account the distinct requirements of each offering.
Maintain coding and regulatory compliance: Align audit concepts with applicable industry standards, including Centers for Medicare & Medicaid Services (CMS) guidance, Medically Unlikely Edits (MUEs), CPT and HCPCS coding guidelines, and other relevant payment rules.
Develop coding unbundling audits: Create, validate, and maintain audit concepts that identify inappropriate coding unbundling in accordance with National Correct Coding Initiative (NCCI) edits.
Analyze audit performance: Investigate discrepancies in concept outcomes and collaborate with clinical, coding, and operations teams to determine root causes and implement corrective actions.
Benchmark and optimize results: Compare audit outcomes against industry standards, historical performance, and client-specific baselines to identify performance gaps and opportunities for improvement.
Validate automated audit logic: Participate in testing new and updated concepts to confirm that automated rules perform accurately within system environments before deployment.
Ensure pre-deployment accuracy: Verify that audit concepts reflect current coding guidelines, payment methodologies, and payer policies before implementation.
Promote consistent policy application: Support audit teams in applying policies accurately and consistently across technology platforms, client programs, and operational workflows.
Collaborate on payment integrity initiatives: Partner with clinical, coding, operations, client services, and IT teams to develop audit strategies, clinical and coding solutions, and policy improvements.
Improve workflows and documentation: Identify opportunities to streamline audit concept development, strengthen documentation standards, improve tracking processes, and enhance cross-functional coordination.
Leverage AI and automation: Use AI-powered tools and automation platforms to accelerate policy research, support clinical content development, improve operational efficiency, and scale payment integrity solutions.
Support additional business priorities: Contribute to ad hoc projects and other responsibilities as needed to support organizational objectives.
Requirements:
Relevant industry experience: At least three years of experience in healthcare payment integrity, facility claims auditing, or a closely related field.
Required professional certification or license: At least one of the following credentials: Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Professional Coder (CPC), or Certified Professional Medical Auditor (CPMA). An active Registered Nurse (RN) or Licensed Practical Nurse (LPN) license is also accepted.
Regulatory policy expertise: Demonstrated ability to interpret complex healthcare regulations, payer guidelines, and medical requirements and translate them into clear, compliant clinical content and structured policy documentation.
Medical coding knowledge: Strong understanding of Medicare and commercial coding rules, reimbursement regulations, prospective payment systems, and national coding standards, particularly those related to healthcare payment policies.
Claims and reimbursement expertise: Broad knowledge of medical claims billing and payment systems, facility billing guidelines, provider reimbursement rules, payer policies, medical necessity criteria, and medical coding terminology.
Facility reimbursement methodologies: In-depth understanding of different facility reimbursement models and commercial and government payment policies, with the ability to support contractual compliance and audit accuracy.
Analytical and research capabilities: Strong research, data analysis, and problem-solving skills, including the ability to assess claims information, evaluate audit performance, identify discrepancies, and recommend improvements.
Technical documentation skills: Ability to develop, maintain, and validate audit rules, code lists, policy documents, and structured clinical content with a high degree of accuracy and attention to detail.
AI and automation proficiency: Demonstrated experience using AI tools or automation platforms to improve clinical research, streamline policy development, or enhance operational workflows.
Microsoft Office proficiency: Strong working knowledge of Microsoft Office applications, including Excel, Word, Outlook, PowerPoint, SharePoint, and Teams.
Communication and collaboration: Excellent written and verbal communication skills, with the ability to explain complex regulatory and coding requirements to colleagues, cross-functional teams, and clients at different organizational levels.
Organization and prioritization: Strong organizational skills and the ability to manage multiple projects, balance competing priorities, meet deadlines, and maintain accurate documentation.
Adaptability and continuous improvement: A proactive approach to identifying process improvements, responding to changing regulatory requirements, and collaborating with colleagues to strengthen audit effectiveness.
Remote work readiness: Ability to work independently in a fully remote environment while maintaining effective communication and coordination with distributed teams across the United States.
Benefits:
Competitive base salary: Annual salary ranging from $85,000 to $110,000, depending on skills, experience, qualifications, and geographic location.
Fully remote work: The flexibility to work remotely from anywhere within the United States.
Medical coverage: Access to comprehensive medical insurance options.
Dental and vision insurance: Benefits designed to support employees' overall health and well-being.
Flexible spending and health savings accounts: Access to FSA and HSA options to help manage eligible healthcare expenses.
Retirement savings: A 401(k) plan with employer matching contributions.
Tuition reimbursement: Financial support for eligible educational and professional development opportunities.
Health and wellness perks: Additional benefits and resources designed to support personal well-being.
Flexible and supportive environment: A digital-first workplace that encourages autonomy, collaboration, and the ability to perform at your best.
Professional growth: Opportunities to develop expertise in healthcare regulations, coding methodologies, payment integrity solutions, and AI-enabled workflows.
Inclusive workplace: A commitment to equal employment opportunity and reasonable accommodations throughout the recruitment and employment process.