Research Medicare Coverage Analysis Specialist

                    

At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day.

                        

We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One.

                                    

Job Title

Research Medicare Coverage Analysis Specialist

                        

Location

Cleveland

                    

Facility

Cleveland Clinic Main Campus

                     

Department

CRAO Central Administration-Research Innov and Educ

                      

Job Code

T97705

                     

Shift

Days

                       

Schedule

8:00am-5:00pm

                       

Job Summary

                         

Job Details

Join Cleveland Clinic’s Main Campus where research and surgery are advanced, technology is leading-edge, patient care is world class and caregivers are family. Here, you will work alongside a passionate and dedicated team, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world.    

 

As a Research Medicare Coverage Analysis Specialist, you will be responsible for determining qualifying clinical trial status and performing detailed coverage analyses in accordance with National Coverage Decision NCD310.1 and the Federal Clinical Trials Policy. In this role, you will report to the Director of Research Medicare Coverage Analysis and ensure compliant research billing practices by reviewing clinical trial protocols and regulatory documents to assess all patient care items and services required per the study, as well as determine the final billing designation for all procedures within a clinical research project.  

 

This position is part of a brand-new department at the Cleveland Clinic and offers the opportunity to work as a team member providing Medicare Coverage Analysis for a variety of research projects across the enterprise. The role will establish the centralized MCA Office to ensure billing compliance, protect the organization and patients, and improve operational efficiency. This role is critical to achieving these goals, standardizing processes, and safeguarding Cleveland Clinic’s reputation and financial stability. It is also essential to mitigate the risks of improper billing in clinical trials, which can lead to significant fines, penalties, reputational damage, and exclusion from federal programs. 

 

We have three openings for this position.

 

A caregiver in this position works a hybrid schedule from 8:00 a.m. – 5:00 p.m., working two to three days per week remotely and on-site at Main Campus for the remaining days. 

 

A caregiver who excels in this role will:  

• Responsible for making determinations of qualifying clinical trial status and performing detailed coverage analysis as required by NCD 310.1 and the Federal Clinical Trials Policy.
• Ensure compliant research billing practices are followed by reviewing clinical trial protocols, related regulatory documents, clinical trial agreements, informed consent documents, any documents from the FDA and CMS, and the study budget to assess all patient care items and services per the study protocol.
• Research and apply policies from various sources such as federal, state, CMS website, and professional practice guidelines in making coverage determinations.
• Document justification for coverage analysis by citing specific resources for coverage determinations.
• Assist in the management of claims review by applying the appropriate CDM and/or CPT codes for potentially billable items and services as well as identifying items and services that are billable to the research sponsor.
• Collaborate and communicate effectively with the Principal Investigator and research team, patient financial services, clinical research billing office, IRB, and research compliance related to Medicare coverage analysis issues and determinations.
• Keep current on FDA and Medicare regulations and state laws that apply to clinical trials research billing.
• Assist the MCA Director on the development of tools and billing grids for the Medicare Coverage Analysis process.
• Other duties as assigned.

 

Minimum qualifications for the ideal future caregiver include:  

• Bachelor’s degree in Healthcare Administration, Medical Coding, Auditing, Finance, Accounting, Nursing or a related field and four years of relevant experience in research billing, compliance, and/or direct involvement with sponsored clinical trials
• In lieu of degree, six years of relevant experience in research billing, compliance, and/or direct involvement with sponsored clinical trials
• Excellent oral and written communication skills and the ability to effectively communicate with the Principal Investigator, research team, central offices and study Sponsor
• Ability to interpret and comprehend complex clinical research protocols, interpret research contracts, study budgets and consent forms to extrapolate billing/coverage data
• Ability to manage high volume workload and meet required deadlines

 

Preferred qualifications for the ideal future caregiver include: 

• Coding or Research experience 
• Ability to navigate the CMS website to determine local and national coverage decisions 
• Scientific or healthcare background (i.e. Billing or clinical trials) 

Physical Requirements:

• Ability to perform work in a stationary position for extended periods. 
• Ability to operate a computer and other office equipment. 
• Ability to communicate effectively and exchange accurate information. 
• Ability to travel throughout the health system.

Personal Protective Equipment:

• Follows standard precautions using personal protective equipment as required for procedures.

                       

The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances.

Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption.

Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility. 

If applying for a Florida position, please see the following website for more information on the background screening requirements required by the Agency of Health Care Administration: https://info.flclearinghouse.com/

Please review the Equal Employment Opportunity poster. 

                  

Cleveland Clinic is pleased to be an equal employment opportunity employer.