This position is for a senior Medical Policy and Pricing Advisor on the World Trade Center (WTC) Health Program. The advisor will be responsible for developing medical audits, recommending policy changes, and providing expertise on pricing methodologies.

• Conducts medical utilization audits to ensure quality control.
• Provides recommendations to the client on health care policy and procedure development.
• Provides expertise on pricing methodologies, including the Federal Employees’ Compensation Act (FECA), Diagnosis Related Groups (DRGs), Cost to Charge Ratio (CCR), the Outpatient Prospective Payment System (OPPS), Centers for Medicare and Medicaid Services (CMS) PPS Exempt Cancer Hospitals, and other PPS methodologies.
• Develops pricing recommendations for unlisted, miscellaneous, and unpriced codes using FECA, CMS, and other fee schedules.
• Provides training to the client and other stakeholders on proper medical claims billing, pricing methodologies and Program policies and procedures.
• Creates a quarterly FECA fee schedule and recommends annual rates for roll-up codes for Monitoring and Survivor Screening visits.
• Updates and maintains a pricing calculator for FECA rates by zip code.
• Conducts policy and pricing research on other Federal payors, including CMS, Tricare, Veterans Affairs (VA), and the Office of Workers’ Compensation Programs (OWCP).
• Works with the Provider Relations Team to answer provider questions on policy and pricing issues.
• Responds to medical claims appeals.
• Conducts ad hoc research for the internal team and the client.

• Bachelor's degree
• Five or more years of work experience in healthcare administration
• Experience in running or working in a healthcare program in compliance with Federal law and regulations
• Experience working in limited care healthcare programs preferred
• Expert knowledge of Federal fee schedules, including FECA, DRG, CCR, CMS PPS-ExemptCancer Hospitals, and OPPS
• Expert knowledge of CMS and other Federal claims processing rules, regulations and policies in areas such as long term care and durable medical equipment (DME)
• Must be familiar with coding systems including ICD, CPT, HCPCS and DRG
• Experience with Quality Assurance review of medical claims and systems
• Experience in developing medical policies and procedures
• Comprehensive knowledge of medical, administrative, ethical, and legal requirements related to healthcare delivery and privacy of protected patient information
• Proficient in Microsoft Excel
• Knowledge of MicroStrategy preferred
• Strong analytical and problem solving skills
• Ability to work in a team and independently
• Strong verbal and written communication skills
• Ability to obtain and maintain appropriate clearance

PM18