Job Description

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for an IBR Policy and Content Development Analyst based in the United States. As an IBR Policy and Content Development Analyst, you will play a key role in strengthening healthcare payment integrity through accurate clinical policy development and claims auditing solutions. You will leverage your expertise in medical coding, facility billing, reimbursement methodologies, and regulatory requirements to develop, validate, and optimize audit concepts. Working closely with clinical, coding, operations, client services, and technology teams, you will ensure that payment policies are translated into reliable, compliant, and effective audit logic. You will analyze regulatory updates, payer guidelines, and claims data to identify opportunities for improvement and develop solutions that support accurate reimbursement. Your work will contribute to reducing improper healthcare payments, improving operational efficiency, and helping health plans manage costs more effectively. You will also leverage AI-powered tools and automation to streamline research, improve documentation, and enhance the scalability of payment integrity solutions. This fully remote opportunity is ideal for a detail-oriented healthcare professional who combines strong analytical skills with regulatory expertise and a commitment to improving payment accuracy. Accountabilities: - Develop and maintain audit concepts: Review, update, and enhance existing audit concepts according to established review schedules and in response to client requirements, regulatory changes, and evolving coding standards.

- Research regulatory and coding requirements: Analyze changes in healthcare regulations, medical coding guidelines, reimbursement methodologies, and payer policies to assess their impact on existing audit concepts and document findings clearly. - Apply client-specific policies: Interpret and incorporate payer-specific reimbursement rules, medical necessity criteria, and contractual requirements into audit concept reviews and updates. - Interpret government and regional policies: Research and apply state-specific Medicare and Medicaid provider manuals, regional regulatory requirements, and applicable government payment guidelines to audit configurations. - Identify new audit opportunities: Evaluate payer policies and claims trends to identify coverage gaps, reimbursement inconsistencies, and opportunities to propose new audit concepts to clients. - Support multiple payment programs: Ensure audit concepts are appropriately developed and maintained across Medicaid, Medicare, and commercial insurance programs, taking into account the distinct requirements of each offering. - Maintain coding and regulatory compliance: Align audit concepts with applicable industry standards, including Centers for Medicare & Medicaid Services (CMS) guidance, Medically Unlikely Edits (MUEs), CPT and HCPCS coding guidelines, and other relevant payment rules. - Develop coding unbundling audits: Create, validate, and maintain audit concepts that identify inappropriate coding unbundling in accordance with National Correct Coding Initiative (NCCI) edits. - Analyze audit performance: Investigate discrepancies in concept outcomes and collaborate with clinical, coding, and operations teams to determine root causes and implement corrective actions. - Benchmark and optimize results: Compare audit outcomes against industry standards, historical performance, and client-specific baselines to identify performance gaps and opportunities for improvement. - Validate automated audit logic: Participate in testing new and updated concepts to confirm that automated rules perform accurately within system environments before deployment.

Job Tags

Similar Jobs