Claims Payment Policy Lead (Contract) Location: Remote (Must reside in Pennsylvania, New Jersey, or Delaware) About the Role We are seeking a Claims Payment Policy Lead to join our Medical/Health Services team. This role sits at the intersection of clinical expertise and business operations, supporting the development and optimization of claim payment and medical policies .You will play a key role in aligning reimbursement policies with industry standards, identifying cost-saving opportunities, and ensuring policies improve affordability while maintaining quality care outcomes. This is a policy development and strategy role—not a chart audit position. What You’ll Do Lead cross-functional collaboration with clinical, coding, and business teams to design and implement claim payment policies. Develop and maintain reimbursement and medical policies aligned with: Nationally recognized standards (e.g., CMS, Medicare)State and federal regulations Internal benefits, contracting, and reimbursement structures Monitor industry trends, regulatory updates, and reimbursement changes to ensure compliance and competitiveness. Analyze utilization patterns and cost drivers to identify opportunities for medical cost sa vings. Create business cases and detailed requirements for policy and coding initiatives. Apply coding expertise to develop and validate accurate code assignments aligned with established guide lines. Present policy proposals and findings to internal committees and stakeholders; incorporate feedback into final deliverables. Serve as a subject matter expert (SME) in clinical and/or coding do mains. Mentor team members and contribute to knowledge sharing across functions. Minimum Qualifications Must reside in PA, NJ, or DE3+ years of clinical experience RN preferred; open to LPN or other licensed healthcare providers (e.g., PT, allied health professionals) 3–5 years of medical coding experience Active coding certification (one or more required): CPC, CCS, RHIA, or RHIT Experience with provider (physician) or facility billing Strong analytical, organizational, and communication skills. Proven ability to collaborate with cross-functional teams and present insights clearly Preferred Qualifications Experience in policy development or reimbursement policy management Familiarity with CMS, Medicare guidelines, and payer alignment strategies Understanding of FDA regulations and approvals. Experience translating clinical and coding insights into actionable business strategies What Success Looks Like Development of clear, compliant, and impactful claim payment policiesIdentification of cost-saving opportunities through data-driven insights Strong collaboration across clinical and business teams Effective communication of policy recommendations to leadership and committees Equal Opportunity Employer Statement We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, age, disability, veteran status, genetic information, or any other legally protected characteristic. We are committed to creating an inclusive environment for all employees and applicants. Candidate Application Questions What clinical license or background do you hold (RN, LPN, etc.)?Which active coding certification(s) do you have? (CPC, CCS, RHIA, RHIT)What are your full- time salary expectations? Do you currently reside in PA, NJ, or DE?