MD Anderson Cancer Center Clinical Reimbursement & Policy Specialist in Houston, Texas

The purpose of the Clinical Reimbursement and Policy specialist is to provide advanced clinical and financial analysis to protect institutional reimbursement for medically necessary clinical services.

Analyze and Monitor Reimbursement and Coverage Trends

Analyze, summarize, and interpret financial and clinical patient data related to reimbursement and medical coverage, to ensure that MD Anderson is appropriately reimbursed for services provided. This includes both quantitative and qualitative analyses using both summary and patient-level claims data to assess reimbursement and coverage performance.

-Accesses institutional sources of clinical and financial data to query, analyze, and summarize reimbursement and coverage trends at the patient level, institutional level and various other levels of summary.

-Discover trends and report them to key stakeholders.

-Determine the root cause of the denials using a variety of sources including the documentation in the patient's medical record; Assess the type of denials using National Payor Reason and Remark codes; Evaluate the use of ICD10 and HCPCS/CPT codes, requiring thorough knowledge of payor remittance information.

-Recommend corrective actions that should be taken.

-Monitor corrective actions to determine their effectiveness.

Payor Expansions and Appeals Support

Assist in preparing coverage expansion requests and bundled claim appeals by:

-Interpreting various payor medical policies.

-Researching peer-reviewed journal articles and other medical literature.

-Locating and understanding necessary information in the patient's medical record including anatomy terms.

-Drafting persuasive letters to support individual appeals and Expansion Requests.

Medical Coverage Support

Assess Medical Coverage of new or existing services and make appropriate interpretations of coverage status and financial impact to the institution. Support compliance with payor policies and reduction in delivery of non-covered services by developing and maintaining tools to support compliance and operations, such as:

-Reviewing the Advance Beneficiary Notice (ABN) Drug grid in accordance with Novitas's Local Coverage Determination (LCD).

-Updating and maintaining the Molecular Pathology medical coverage grid for the Financial Clearance Center's (FCC) use.

-Assist in developing and maintaining any other tools to assist customers.

-Maintaining current knowledge of common and emerging oncology treatments and services.

EDUCATION

Required: Bachelor's degree in Business Administration, Healthcare or related field.

Preferred: Degree in Nursing, HIM, or related clinical or business specialty.

CERTIFICATIONS

Preferred: RN, RHIA, or comparable clinical or coding certification.

EXPERIENCE

Required: Eight years of experience with a hospital, managed care company, medicare intermediary, or accounting/consulting firm.

Preferred: Both clinical and business analytics experience.

It is the policy of The University of Texas MD Anderson Cancer Center to provide equal employment opportunity without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, disability, protected veteran status, genetic information, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. http://www.mdanderson.org/about-us/legal-and-policy/legal-statements/eeo-affirmative-action.html

Additional Information

  • Employee Status: Regular

  • Minimum Salary: US Dollar (USD) 78,800

  • Midpoint Salary: US Dollar (USD) 98,500

  • Maximum Salary : US Dollar (USD) 118,200