Rialtic · 18 hours ago
Payment Accuracy Policy Manager, Drugs
United States
Full-time
Remote
Mid, Senior LevelRialtic is an enterprise software platform empowering health insurers and healthcare providers to run their most critical business functions. The Payment Accuracy Policy Manager will drive program management and policy support for clinical edits for hundreds of drugs, ensuring effective claims processing and collaboration with clinical teams.
Enterprise SoftwareHealth CarePayments
Responsibilities
Review healthcare policies and determine the logics to create based on strategic and technical considerations
Create functional designs and test claims from concept through validation and maintenance
Review, edit and finalize designs and test claims assigned to content analysts
Mentor and coach content analysts on conceptualizing, creating and delivering claims processing edits and improving claims processing designs and test claims
Create and manage special projects and programs from concept through execution and maintenance
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
Drive prioritization of drug library (partner withour clinical team and go to market teams, plus leverage internal data, to prioritize which drugs will be developed)
Curating drug edit scoping templates before handing off to the production process
Partnering with our clinical teams to review & respond to Validation questions
Identify and create business cases for any system enhancements to support any unique needs for the Drug Edits (partner with Product or Engines to prioritize the enhancements)
Partner with our Clinical Leadership on providing content development & maintenance, including building the “clinical adherence updates” (aka maintenance) process for managing the covered indications and dosages of each drug
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
Perform sampling and validation with client data of beta and in-production claims edits
This includes:
Reviewing, interpreting, and creating updates from the review of clinical literature related to the off-label use of drugs
Monitoring and making policy changes in accordance with FDA labels, compendia drug sources, and payer policies
Researching new clinical literature and journal articles to identify changes that need to be made to policies
Provide policy support for client inquiries on the drug edits
Qualification
Required
RN or Pharmacist required
Project Management experience
Payment Integrity experience
Preferred
Oncology experience preferred
Drug dosing calculation experience
Experience using Google product suite, including Google sheets preferred
Benefits
Freedom to work from wherever you work best and a home office stipend to make it happen
Meaningful equity and 401 (k) matching
Flexible, Open PTO Plan
Wellness Stipend
Comprehensive health plans with generous contributions to premiums
Mental and physical wellness support through TalkSpace, Teladoc and One Medical subscriptions
Company
Rialtic
Rialtic operates an open marketplace enterprise platform designed to equip and assist payers to make accurate healthcare payments.
Founded in 2020
51-200 employees
Funding
Current Stage
Growth StageTotal Funding
$79.71MKey Investors
F-PrimeOak HC/FT
2023-08-04Series Unknown· $36.71M
2022-03-02Series A· $28M
2020-10-22Series A· $15M
Leadership Team
J. Douglas Williams
Founder
Roy Ziegler
Advisory Board
Recent News
2024-04-13
Payments Dive
2024-01-20
The Business Journals
2023-12-22
Company data provided by crunchbase