Job Title: Claims Payment Policy Lead (Clinical + Coding) Location: Remote (Must reside in PA, NJ, or DE) About the Role We are seeking a Claims Payment Policy Lead to support a dynamic Medical/Claims Policy team. This role sits at the intersection of clinical expertise and healthcare coding/billing, focusing on policy development (not audits) to drive cost efficiency and align with industry standards. Key Responsibilities Lead policy-driven initiatives to identify and implement medical cost-saving opportunities Develop and maintain claim payment and medical policies aligned with: CMS/Medicare guidelines, Industry reimbursement practices, State & federal regulations Monitor industry trends and regulatory changes Analyze utilization patterns and claims data to recommend improvements Develop business cases and policy documentation. Serve as a clinical and/or coding SME and mentor team members Ensure accurate coding alignment (CPT, HCPCS, ICD guidelines) Required Qualifications Must reside in PA, NJ, or DE Clinical background (3+ years): RN preferred (open to LPN or other licensed healthcare professionals – PT, allied health, etc.) 3–5 years of Medical Coding experience Active certification required- CPC, CCS, RHIA, or RHIT Strong provider or facility billing experience