Reimbursement Policy Analyst

HealthPartners is hiring a Payment Integrity Reimbursement Policy Analyst. They are responsible for the development, maintenance, implementation, and governance of reimbursement policies that support accurate claims adjudication and payment integrity initiatives across professional and facility healthcare services. The analyst serves as a subject matter expert in reimbursement methodologies, coding guidelines, payment policies, and regulatory requirements, ensuring alignment between reimbursement policy intent and operational claim processing.

This position collaborates closely with Claims Operations, Provider Contracting, Medical Policy, Clinical Operations, Compliance, Legal, Information Technology, and Payment Integrity teams to design, implement, monitor, and optimize reimbursement policies that promote payment accuracy, regulatory compliance, operational efficiency, and provider transparency.

MINIMUM QUALIFICATIONS:

Education, Experience or Equivalent Combination:

Bachelor's degree in Healthcare Administration, Business Administration, Health Information Management, Finance, Public Health, Nursing, or a related field.

Minimum 5 years experience working with HMO, fully insured, indemnity, and government programs

Prior experience in medical claims processing and adjudication

Experience using coding software platforms and system editing tools

Demonstrated ability to independently analyze and adjudicate complex claims scenarios

Equivalent combination of education and relevant healthcare reimbursement experience may be considered.

Licensure/ Registration/ Certification:

CPC, CCA, CCS or equivalent (required)

Knowledge, Skills, and Abilities:

Strong understanding of health plan claims adjudication processes.

Knowledge of reimbursement methodologies, including:

Medicare Physician Fee Schedule

APC reimbursement

DRG reimbursement

Multiple procedure reductions

Bundling and unbundling logic

NCCI edits

Modifier application

Strong working knowledge of:

CPT

HCPCS

ICD-10-CM

CMS regulations

LCDs and NCDs

Strong analytical and problem-solving skills.

Exceptional written communication and policy development abilities.

Advanced proficiency with Microsoft Excel, Word, PowerPoint, and data-analysis tools.

Ability to make independent decisions and complex judgment calls

Strong organizational, planning, and prioritization skills

Effective communication skills across technical and business stakeholders

PREFERRED QUALIFICATIONS:

Education, Experience or Equivalent Combination:

Bachelor’s degree in a related field

3-7+ years of experience in the healthcare industry in one or more of the following:

Payment Integrity

Reimbursement Policy

Claims Operations

Medical Coding

Provider Reimbursement

Healthcare Revenue Cycle

Health Plan Operations

Equivalent combination of education and relevant healthcare reimbursement experience may be considered.

Licensure/ Registration/ Certification:

Advanced or specialty coding certifications preferred

Knowledge, Skills, and Abilities:

Deep familiarity with coding governance, audit processes, and reimbursement methodologies

Experience supporting policy development and coding compliance initiatives

ESSENTIAL DUTIES:

(25%) Reimbursement Policy Development

Research, develop, revise, and maintain reimbursement policies for professional, facility, laboratory, pharmacy, and ancillary healthcare services.

Interpret and apply Medicare, Medicaid, commercial payer, and industry reimbursement requirements.

Evaluate coding and reimbursement issues involving CPT®, HCPCS Level II, ICD-10-CM, ICD-10-PCS, DRG, APC, and revenue code methodologies.

Draft clear policy language for provider-facing reimbursement policy documents.

Ensure policies align with organizational objectives, provider contracts, benefit administration requirements, and applicable regulations.

(20%) Payment Integrity Analysis

Identify reimbursement opportunities through analysis of claims data, payment trends, coding patterns, and audit findings.

Evaluate the financial and operational impact of proposed reimbursement policy changes.

Monitor payment integrity initiatives and recommend policy enhancements to improve claim payment accuracy.

Support pre-payment and post-payment review activities.

Analyze and resolve complex reimbursement questions escalated from operational teams.

(20%) Claims Editing and System Configuration

Perform trend analysis to identify billing patterns, reimbursement impacts, and revenue opportunities

Evaluate coding edits and business rules to ensure optimal system performance

Identify opportunities to reduce claim inventory and improve financial outcomes

Support data-driven decision making through analytics and reporting

(15%) Regulatory and Industry Monitoring

Maintain awareness of:

CMS regulations and guidance

NCCI Policy Manual updates

Medicare National Coverage Determinations (NCDs)

Local Coverage Determinations (LCDs)

Commercial payer reimbursement practices

CPT and HCPCS annual updates

Assess regulatory changes and recommend necessary policy revisions.

(10%) Program Governance

Participate in reimbursement policy governance processes.

Maintain documentation supporting policy decisions, implementations, revisions, and approvals.

Prepare reports and presentations regarding policy initiatives, financial impact, and operational outcomes.

Support continuous improvement efforts across Payment Integrity operations.

(10%) Appeals and Audit Support

Assist with review of provider disputes, reconsiderations, and payment appeals involving reimbursement policy application.

Support internal and external audits related to reimbursement methodologies and payment integrity initiatives.

Provide documentation supporting payment decisions and policy rationale.

At HealthPartners we believe in the power of good – good deeds and good people working together. As part of our team, you’ll find an inclusive environment that encourages new ways of thinking, celebrates differences, and recognizes hard work.

We’re a nonprofit, integrated health care organization, providing health insurance in six states and high-quality care at more than 90 locations, including hospitals and clinics in Minnesota and Wisconsin. We bring together research and education through HealthPartners Institute, training medical professionals across the region and conducting innovative research that improve lives around the world.

At HealthPartners, everyone is welcome, included and valued. We’re working together to increase diversity and inclusion in our workplace, advance health equity in care and coverage, and partner with the community as advocates for change.

Benefits Designed to Support Your Total Health As a HealthPartners colleague, we’re committed to nurturing your diverse talents, valuing your dedication, and supporting your work-life balance. We offer a comprehensive range of benefits to support every aspect of your life, including health, time off, retirement planning, and continuous learning opportunities. Our goal is to help you thrive physically, mentally, emotionally, and financially, so you can continue delivering exceptional care.

Join us in our mission to improve the health and well-being of our patients, members, and communities.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant because of race, color, sex, age, national origin, religion, sexual orientation, gender identify, status as a veteran and basis of disability or any other federal, state or local protected class.