Cambia Health Solutions Manager of Policy and Implementation in Seattle, Washington


The Manager of Policy and Implementation plans, directs, and manages the activities of the Reimbursement Policy and Implementation team. You will versee staff directly or through subordinate supervisor(s), provide leadership to set performance standards and ensure effective and efficient execution of clinical editing and reimbursement policies. You will additionall represent the department in interactions with all levels of management, vendor partners, clients, providers, government officials, and outside consultants.

Responsibilities & Requirements

  • Leads the maintenance and implementation of clinical edits and reimbursement policies to meet the needs of internal and external customers. Oversees the implementation of policy updates or process improvements as needed to ensure quality and service excellence. Enables system payment rule consistency,

  • Handles all management level responsibilities for staff, including performance reviews, employee development, hiring, coaching, counseling, and retention. Develops supervisors and participates in talent management activities.

  • Regularly communicates organizational objectives and team goals. Monitors results and metrics to ensure strategic goals and deliverables are met and compliance with department and regulatory standards. Collaborates with other leaders and across departments to resolve issues.

  • Provides oversight of day-to-day operations of vendor(s) performing clinical editing. Manages and reports monthly on vendor performance. Manages relationship with vendor. Ensures operational efficiency within Policy & Implementation and other impacted departments of Regence. Develops workflows, procedures and desk reference for team interactions with vendor.

  • In conjunction with division leadership, establishes long-term goals for department and adapts operational plans as changes occur.

  • Creates visibility and support for policy and implementation programs. Develops resource materials and provides education and communication about programs to employees, providers and community stakeholders.

  • Maintains clinical competency and keeps current on medical practices, procedures and industry trends.

  • May develop and present educational updates to other departments.

  • Manages the business and system implications between coding, reimbursement, editing and benefit teams.

  • Ensures timely and accurate monthly clinical editing system updates. Anticipates plans and coordinates with appropriate areas to ensure systems meet current and future editing needs.

  • Supervises 8-15 FTEs.

Competencies and Knowledge:

  • Ability to understand, translate and communicate technical and complex ideas and situations to a wide variety of audiences.

  • Ability to identify issues, opportunities, and effective solutions and collaborate with other departments to improve processes and/or results.

  • Demonstrated knowledge of provider billing practices, provider reimbursement methodologies, medical claim coding, and medical and reimbursement policies.

  • Proficient experience with claims and other clinical data, corporate reimbursement and medical policies, and the application of clinical or other automated editing systems.

  • Demonstrated competency in resource and project management: budgeting, organizing work, providing leadership to staff, establishing measures for success, and managing to deliverables.

  • Ability to develop and lead a team including: hiring, goal setting, coaching and development (including supervisors and/or employees who may be in multiple locations or work remotely).

  • Ability to communicate effectively, verbally and in writing, including meeting facilitation and presentations with employer or provider groups.

  • Familiarity with state and federal policy requirements and guidelines, health insurance industry trends and technology.

Normally to be proficient in the competencies listed above:

Manager, Policy and Implementation would have a bachelor’s degree in Business and a combination of 10 years’ experience in provider reimbursement, health insurance medical operations and clinical edits; management experience in data mining, reporting and business support; direct experience implementing large-scale, multi-dimensional projects and healthcare benefits and medical claim coding, or a combination of education and experience.

About Us

At Cambia, we advocate for transforming the health care system. You aren’t satisfied with the status quo and neither are we. We're looking for individuals who are as passionate as we are about transforming the way people experience health care. We offer a competitive salary and a generous benefits package. We are an equal opportunity employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check is required.

Cambia’s portfolio of companies spans health care information technology and software development; retail health care; health insurance plans that carry the Blue Cross and Blue Shield brands; pharmacy benefit management; life, disability, dental, vision and other lines of protection; alternative solutions to health care access; and free-standing health and wellness solutions.We have a century of experience in developing and providing health solutions to serve our members. We had our beginnings in the logging communities of the Pacific Northwest asinnovators in helping workers afford health care. That pioneering spirit has kept us at the forefront as we build new avenues to improve access to and quality of health care for the future.

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Requisition ID2018-25282

Category (Portal Searching)Claims/Appeals