Claims Payment Policy Lead / Payment Integrity Analyst

About the role

We are seeking an experienced Claims Payment Policy Lead to join our Claim Payment Policy team in Philadelphia. This hybrid role combines clinical expertise with business operations to develop and maintain reimbursement and medical payment policies that ensure payment accuracy, cost‑effective utilization, and regulatory compliance.

Key responsibilities

• Develop, maintain, and enhance medical and reimbursement policies aligned with national standards, benefit structures, provider contracts, and federal and state regulations.
• Use clinical expertise and knowledge of CPT, HCPCS, and ICD‑10 coding to evaluate claims trends and support appropriate reimbursement practices.
• Monitor payment policy trends across the healthcare landscape to identify opportunities for cost containment and improved member affordability.
• Create and present Claim Payment Policy Bulletins and findings to internal workgroups and leadership committees.
• Collaborate with cross‑functional teams as a subject‑matter expert for clinical and coding‑related initiatives, analyses, and projects.
• Support business case development and strategic initiatives related to payment integrity and utilization management.
• Partner with vendors, consultants, and internal stakeholders to keep policies current and aligned with regulatory and industry changes.
• Contribute to the evolution of the Claim Payment Policy function as the organization integrates clinical and business perspectives.

Required profile

• Active healthcare licensure preferred (RN strongly preferred; LPN, PT, OT, or other allied health professionals considered).
• Valid coding certification such as CPC, CCS, RHIA, or RHIT.
• Minimum 3+ years of clinical experience, ideally in a nursing capacity.
• Minimum 3–5 years of hands‑on medical coding experience (beyond certification alone).
• Experience with physician/provider billing and/or facility billing.
• Strong understanding of healthcare reimbursement principles and insurance payment methodologies.
• Excellent analytical, communication, and presentation skills.

Required skills

• CPT coding
• HCPCS coding
• ICD‑10 coding
• Medical coding
• Coding certifications (CPC, CCS, RHIA, RHIT)