Payment Integrity Content Portfolio Manager

Summary

Join Rialtic, a healthcare technology company, as a Content Portfolio Manager for Drugs and Biologicals. You will manage the FDA Drugs and Biologicals portfolio, encompassing scoping, design, and quality control. This role involves managing both on and offshore resources while also contributing to the development of professional edits for drugs and biologicals. A significant portion of the role focuses on interpreting FDA drug labels and clinical articles to create accurate coding edits. You will also educate and mentor content analysts, develop timelines, and ensure policy requests are met. The ideal candidate possesses extensive experience in payment integrity, medical coding certifications, and a deep understanding of drug and biological claims processing.

Requirements

• 4-6 years of work experience in payment integrity with a health plan or claims editing vendor with a focus on drugs and biologicals
• Medical coding certification from AAPC, AHIMA, or other body, equivalent medical coding/billing college degree
• Experience making medical coding edits for drugs and biologicals for claims editing vendor and/or payer
• Experience reading and interpreting FDA drug labels, clinical/academic journals, and special societies guidelines to create medical coding edits for drugs and biologicals for professional claims including on and off-label indications
• Expertise with National Drug code data and edits for National Medicare and State Medicaids
• Coding, Billing, and/or Auditing Credentials or any certified coding specialty
• Advanced Google Suite skills
• Deep knowledge of claims edits’ top error reasons, client value, and analytics
• Expert in interpreting medical policies and applying correct coding guidelines
• Expertise in multiple medical coding and/or billing specialties
• Expertise in professional and institutional claims
• Experience explaining medical policies and payment accuracy to clients
• Managed claims editing implementations
• Strong verbal communication skills
• Experience presenting on client calls, answering client questions, and negotiating client requests with internal resources

Responsibilities

• Understand how to interpret FDA drug labels and clinical articles to create correct coding drugs and biological edits for professional claims
• Create, review and maintain edits
• Educate, mentor and coach content analysts on creating and delivering quality output
• Develop timelines for initiatives and manage teams to meet deliverables
• Ensure policy requests are understood, addressed, and executed as determined
• Explain drugs and biologicals policy edits to clients
• Increase policy adoption and drive savings rates for drugs and biologicals edits
• Review Medicare, Medicaid, commercial, FDA, NDC and other sources to determine correct coding edits to design
• Create and manage special projects and programs from concept through execution and maintenance
• Provide expertise to guide the prioritization and roadmap of edits pertinent to your top knowledge areas
• Develop a Roadmap to guide the creation of your portfolio of claims processing edits
• Validate edits with claims data
• Troubleshoot edits that do not function as expected and collaborate with Engineering teams to resolve and adjust design and test claims to make edits function as intended

Benefits

• Freedom to work from wherever you work best and a home office stipend to make it happen
• Meaningful equity and 401k matching
• Unlimited PTO and wellness reimbursements
• Comprehensive health plans with generous contribution to premiums
• Mental and physical wellness support through TalkSpace, Teladoc, and One Medical subscriptions