Pricing Conslt - Novitas

Are you interested in joining a team of experienced healthcare experts and have the ability to shape and transform the healthcare delivery system? At our family of companies, everything we do is to help improve the lives of the nearly 12 million Medicare beneficiaries we serve and 700,000 health care providers who care for them. It is our goal to help create a better health experience for all consumers. Join our winning culture and help transform Medicare for the millions of people who rely on its services.

Benefits info:
* Medical, dental, vision, life and supplemental insurance plans effective the first day of the month following date of hire
* Short- and long-term disability benefits
* 401(k) plan with company match and immediate vesting
* Free telehealth benefits
* Free gym memberships
* Employee Incentive Plan
* Employee Assistance Program
* Rewards and Recognition Programs
* Paid Time Off and Paid Sick Leave

SUMMARY STATEMENT

This highly visible role is responsible for the development, operationalization, and communication of the accurate pricing and reimbursement of codes and services for all contractor priced codes as directed by the Centers for Medicare and Medicaid Services. This position creates local fees for procedure codes and services not priced by CMS and ensures the fees are established in compliance with all Medicare rules and regulations.

ESSENTIAL DUTIES & RESPONSIBILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.

Analysis & Research (50%)

* Performs cost/price analysis including cost breakdown to determine reasonableness and conformance to applicable pricing regulations, directives and policies.

* Researches and evaluates all codes not priced by CMS from a clinical and claims processing perspective.

* Develops pricing methodologies and local fees.

* Responsible for ensuring beneficiary access to care through development of local fees that are geographically appropriate.

* Directs the implementation of claims processing edits as appropriate in the applicable claims processing systems- Multi-Carrier System (MCS) and/or Fiscal Intermediary Shared System(FISS).

* Leads the Pricing Committee, a collaborative internal team which includes Contractor Medical Director (CMDs) and Medical Affairs leadership, in fee development, processing, pricing and payment issues, as well as identifying issues that may have an impact on the Medicare Program on a local or national level from a billing, coding, or payment perspective.

* Meets with external stakeholders (e.g., vendors CEOs, Medical Directors) regarding new technology, procedures, and services to gather information to assist in the development of a local fee when appropriate.

* Provides guidance regarding claims edit issues the Medical Affairs team, CMDs, the provider outreach and education team, and operations (i.e., Claims and Appeals) to ensure compliance and proper claims processing.

* Actively participates in the American Medical Association (AMA) Current Procedural Terminology (CPT) and Relative Value Scale Update Committee (RUC) through the comment process.

* Actively follows the CMS proposed and final rules as well as the various CMS quarterly meetings and updates.

* Actively participates in national pricing workgroup meetings with all other MACs.

* Evaluates medical record documentation to ensure contractor price codes are accurately coded and priced.

Change Management (35%)

* Interprets and applies laws, regulations and policies that govern the operation, management and data activities associated with contractor pricing to ensure accurate and effective implementation.

* Evaluates and provides direction for implementation of Change Requests and Technical Direction Requests regarding local pricing /fee development to ensure accurate and timely completion.

* Evaluates the CMS quarterly and annual code updates and provides direction for accurate and timely implementation of local pricing /payment instructions.

* Leads organizational workgroup meetings to discuss and implement claims processing changes and education of local pricing /payment instruction.

* Identifies claims and provider reimbursement-related system issues including coding and processing issues, coordinates research, and implements and monitors system changes to resolve any problems.

* Routinely and proactively collaborates with team members including the CMDs, senior leadership, and operational leads as necessary to identify and implement improvements related to pricing, proper coding, related claim processing and operationalization.

* Formulates and recommends needed revisions or changes to existing pricing policies, criteria, standards, and procedures.

Provider Surveys and Projects (15%)

* Provides guidance and direction as it relates to the development and execution of jurisdictional pricing surveys.

* Performs all tasks associated with complex pricing projects that require extensive research, evaluation and mathematical calculations to meet the CMS requirements for the gap filling of clinical laboratory services as well as blood products provided in the End Stage Renal Disease (ESRD) facilities.

* Performs all tasks associated with the complex annual portable x-ray pricing review and the five-year cost analysis required by CMS.

* Performs complex pricing projects that are considered controversial and/or unique in nature. These tasks require extensive research, evaluation and calculations to ensure providers will receive reimbursement that is accurately aligned with the industry resource-based relative value scale and geographic practice cost indexes.

* Collaborates with the team to ensure accurate and timely communication with and gathering of information from stakeholders, analysis of the information received, follow-up stakeholder communication as needed, and appropriate fee development in keeping with the CMS related requirements.

* Meets with external stakeholders when re-evaluating a fee to ensure accuracy and comprehensiveness of information.

* Routinely and proactively collaborates with providers, medical associations and specialty societies, relative to the local pricing process.

Performs other duties as the supervisor may, from time to time, deem necessary.

REQUIRED QUALIFICATIONS

* Master's degree in Public Health, Science or similar field

* 10 years' Medicare experience which includes Part B and Part A coding and related chart review, including not otherwise classified (NOC) and Category III (T codes).

* Extensive knowledge of the international classification of disease, ninth edition, clinical modification (ICDCM), ICDPCS, procedural coding, healthcare common procedure system (HCPCS/current procedural terminology (CPT) nomenclature, medical and procedural terminology, anatomy and physiology, pharmacology, and disease processes to perform the duties described.

* Proficient in FISS/MCS claims processing systems; working knowledge of audits/edits/Expert Claims Processing System (ECPS) events as it relates to the claims processing system.

* Experience developing fees for services and setting code rates.

* Proficient in Current Procedural Terminology (CPT), Healthcare Common procedure Coding System (HCPCS), ICD-10 coding, medical terminology and anatomy/physiology.

* Proven knowledge of Medicare regulations and the ability to evaluate the proposed and final rules for Inpatient Prospective Payment System (IPPS), Outpatient Prospective Payment System (OPPS), and Medicare Physician Fee Schedule Database (MPFSD).

* Proven knowledge of the Resource Based Value Scale and geographic practice cost index.

* Experience surveying the provider community, evaluating the data results and implementing changes.

* Advanced knowledge of computers (e.g., Microsoft Office, internet research), keyboard skills, and various pricing/coding applications (e.g., Optum, Micromedex) and claims processing systems (e.g., FISS/MCS, edits/audits, Expert Claims Processing System events).

* Proven attention to detail.

* Proven ability to research and evaluate complex medical literature and studies.

* Proven understanding of physician charge practices and billing methodologies.

* Excellent oral and written communication skills, interpersonal skills with confidence to present complex medical coding issues and educational instruction to a diverse audience.

* Ability to communicate with confidence with medical professionals, industry, and other external stakeholders.

* Organizational, analytical, time management, statistical and problem-solving skills.

* Proven ability to work independently, as well as in a team environment.

* Certified Professional Coder

PREFERRED QUALIFICATIONS

* Professional licensed clinical experience (e.g., nursing, physician's assistant, physical therapist)

The Federal Government and the Centers for Medicare & Medicaid Services (CMS) may require applicants to have lived in the United States for a minimum of three (3) years out of the last five (5) years to be employed with the Company. These years of residence do not have to be consecutive.

"We are an Equal Opportunity/Protected Veteran/Disabled Employer."

This opportunity is open to remote work in the following approved states: AL, AR, FL, GA, ID, IN, IO, KS, KY, LA, MS, NE, NC, ND, OH, PA, SC, TN, TX, UT, WV, WI, WY. Specific counties and cities within these states may require further approval. In FL and PA in-office and hybrid work may also be available.