Policy Design Specialist I - Remote

Overview

The Policy Design Specialist role is responsible for managing health plan clients and executing monthly project requests. Perform policy configuration maintenance of current medical policies along with implementing new health plan medical policies per client request. Adhere to and remain in alignment with the most up to date healthcare industry medical coding guidelines. Perform data analysis to determine how to accurately apply coding updates and client requested customizations. Execute quality assurance checks to ensure appropriate claim editing recommendations are applied based on client request.

In Short

• Implement new policies and update existing policies for clients.
• Write and design client requested policies from scratch.
• Execute projects requests and monitor queues.
• Balance multiple priorities for healthcare clients.
• Provide high-level customer service and document client needs.
• Meet production and quality targets with accuracy.
• Perform regular quality checks and troubleshooting.
• Participate in peer reviews and provide feedback.
• Analyze client claim data for appropriate editing.
• Maintain knowledge of internal applications and participate in training.

Requirements

• Bachelor's Degree preferred or equivalent work experience.
• Coding or HIM credential preferred (RHIA, CPC, etc.).
• 1+ years of experience with medical terminology and policies.
• 2+ years in claim payment/adjudication and hospital administration.
• Proficient with Microsoft Office Suite.
• Experience with SQL preferred.
• Strong analytical and problem-solving skills.
• Ability to work independently and under pressure.
• Excellent verbal and written communication skills.
• Ability to prioritize and manage multiple tasks.

Benefits

• Competitive benefits package including medical, dental, and vision coverage.
• 401(k) savings plans.
• Paid family leave and 9 paid holidays per year.
• 17-27 days of Paid Time Off (PTO) per year.
• Overtime pay for hours worked over 40 per week.
• Flexible work environment with remote options.
• Opportunities for professional development and training.
• Supportive team environment.
• Access to internal resources and tools.
• Engagement in a mission-driven organization.