Reimbursement Policy Analyst

HealthPartners is hiring a Payment Integrity Reimbursement Policy Analyst. They are responsible for the development, maintenance, implementation, and governance of reimbursement policies that support accurate claims adjudication and payment integrity initiatives across professional and facility healthcare services. The analyst serves as a subject matter expert in reimbursement methodologies, coding guidelines, payment policies, and regulatory requirements, ensuring alignment between reimbursement policy intent and operational claim processing.

This position collaborates closely with Claims Operations, Provider Contracting, Medical Policy, Clinical Operations, Compliance, Legal, Information Technology, and Payment Integrity teams to design, implement, monitor, and optimize reimbursement policies that promote payment accuracy, regulatory compliance, operational efficiency, and provider transparency.

MINIMUM QUALIFICATIONS:

Education, Experience or Equivalent Combination:

• Bachelor's degree in Healthcare Administration, Business Administration, Health Information Management, Finance, Public Health, Nursing, or a related field.
• Minimum 5 years experience working with HMO, fully insured, indemnity, and government programs
• Prior experience in medical claims processing and adjudication
• Experience using coding software platforms and system editing tools
• Demonstrated ability to independently analyze and adjudicate complex claims scenarios

• Equivalent combination of education and relevant healthcare reimbursement experience may be considered.

Licensure/ Registration/ Certification:

• CPC, CCA, CCS or equivalent (required)

Knowledge, Skills, and Abilities:

• Strong understanding of health plan claims adjudication processes.
• Knowledge of reimbursement methodologies, including:
• Medicare Physician Fee Schedule
• APC reimbursement
• DRG reimbursement
• Multiple procedure reductions
• Bundling and unbundling logic
• NCCI edits
• Modifier application
• Strong working knowledge of:
  • CPT
  • HCPCS
  • ICD-10-CM
  • CMS regulations
  • LCDs and NCDs
• Strong analytical and problem-solving skills.
• Exceptional written communication and policy development abilities.
• Advanced proficiency with Microsoft Excel, Word, PowerPoint, and data-analysis tools.
• Ability to make independent decisions and complex judgment calls
• Strong organizational, planning, and prioritization skills

• Effective communication skills across technical and business stakeholders

PREFERRED QUALIFICATIONS:

Education, Experience or Equivalent Combination:

• Bachelor’s degree in a related field
• 3-7+ years of experience in the healthcare industry in one or more of the following:
• Payment Integrity
• Reimbursement Policy
• Claims Operations
• Medical Coding
• Provider Reimbursement
• Healthcare Revenue Cycle
• Health Plan Operations
• Equivalent combination of education and relevant healthcare reimbursement experience may be considered.

Licensure/ Registration/ Certification:

• Advanced or specialty coding certifications preferred

Knowledge, Skills, and Abilities:

• Deep familiarity with coding governance, audit processes, and reimbursement methodologies

• Experience supporting policy development and coding compliance initiatives

ESSENTIAL DUTIES:

(25%) Reimbursement Policy Development

• Research, develop, revise, and maintain reimbursement policies for professional, facility, laboratory, pharmacy, and ancillary healthcare services.
• Interpret and apply Medicare, Medicaid, commercial payer, and industry reimbursement requirements.
• Evaluate coding and reimbursement issues involving CPT®, HCPCS Level II, ICD-10-CM, ICD-10-PCS, DRG, APC, and revenue code methodologies.
• Draft clear policy language for provider-facing reimbursement policy documents.
• Ensure policies align with organizational objectives, provider contracts, benefit administration requirements, and applicable regulations.

(20%) Payment Integrity Analysis

• Identify reimbursement opportunities through analysis of claims data, payment trends, coding patterns, and audit findings.
• Evaluate the financial and operational impact of proposed reimbursement policy changes.
• Monitor payment integrity initiatives and recommend policy enhancements to improve claim payment accuracy.
• Support pre-payment and post-payment review activities.

• Analyze and resolve complex reimbursement questions escalated from operational teams.

(20%) Claims Editing and System Configuration

• Perform trend analysis to identify billing patterns, reimbursement impacts, and revenue opportunities
• Evaluate coding edits and business rules to ensure optimal system performance
• Identify opportunities to reduce claim inventory and improve financial outcomes

• Support data-driven decision making through analytics and reporting

(15%) Regulatory and Industry Monitoring

• Maintain awareness of:
  • CMS regulations and guidance
  • NCCI Policy Manual updates
  • Medicare National Coverage Determinations (NCDs)
  • Local Coverage Determinations (LCDs)
  • Commercial payer reimbursement practices
  • CPT and HCPCS annual updates
• Assess regulatory changes and recommend necessary policy revisions.

(10%) Program Governance

• Participate in reimbursement policy governance processes.
• Maintain documentation supporting policy decisions, implementations, revisions, and approvals.
• Prepare reports and presentations regarding policy initiatives, financial impact, and operational outcomes.
• Support continuous improvement efforts across Payment Integrity operations.

(10%) Appeals and Audit Support

• Assist with review of provider disputes, reconsiderations, and payment appeals involving reimbursement policy application.
• Support internal and external audits related to reimbursement methodologies and payment integrity initiatives.
• Provide documentation supporting payment decisions and policy rationale.