Job Title: Claim Payment Policy Lead (Clinical + Coding) Location: PA, NJ, or DE (Remote/Hybrid as applicable) Job Summary We are seeking a Claim Payment Policy Lead to support our Medical/Claims Policy team. This role bridges clinical expertise and medical coding/business functions to develop and maintain claim payment policies. The ideal candidate will bring a strong background in clinical care (RN preferred) along with professional coding certification and billing experience . Key Responsibilities Develop and maintain claim payment and medical policies aligned with national reimbursement standards Collaborate cross-functionally to identify and implement cost-saving policy initiatives Analyze utilization trends and recommend cost-effective healthcare solutions Monitor CMS, regulatory, and industry trends to ensure compliance Apply coding expertise to develop accurate code assignments and reimbursement policies Prepare and present policy bulletins, business cases, and requirement documents Serve as a clinical and/or coding SME and mentor team members Present insights and recommendations to stakeholders and leadership Required Qualifications Must reside in PA, NJ, or DE 3+ years clinical experience (RN preferred; open to LPN, PT, or other allied health professionals) 3–5 years of medical coding experience Active certification: CPC, CCS, RHIA, or RHIT Strong background in provider or facility billing Excellent analytical, communication, and presentation skills Proven ability to work across clinical and business teams Preferred Qualifications Experience in policy development or reimbursement strategy Knowledge of CMS/Medicare guidelines Familiarity with FDA regulations and approvals