Purpose:
The Clinical Trial Coverage Analyst is responsible for ensuring the financial compliance and proper coverage of clinical trial procedures. This role involves reviewing clinical trial protocols to determine what is billable to third-party payers, ensuring alignment with Medicare and other insurance coverage rules, and identifying study-related costs that should be covered by the study sponsor. The specialist collaborates with clinical research teams, finance departments, and compliance to ensure accurate financial planning and billing for clinical trials. This position works with various systems including EPIC EHR and OnCore CTMS for the purpose of segregating charges to ensure compliant billing for research services as well as providing pricing for budgeting purposes.

Responsibilities:

Perform detailed coverage analysis of clinical trial protocols to distinguish billable versus non-billable items and services. Ensure compliance with Medicare’s Clinical Trial Policy and other payer regulations related to clinical research billing. Applies the appropriate CDM and/or CPT codes for potentially billable items in the coverage analysis in order to assist in the management of claims review, as well as identifying items that are to be billed to the sponsor via the budgeting and contract teams. Collaborate with clinical research teams to develop accurate study budgets based on coverage analysis findings. Identify and document which study costs should be covered by the study sponsor versus the payer. Communicate findings to clinical research coordinators, investigators, and financial teams. Synchronizes the final coverage analysis with appropriate final study documents. Maintain up-to-date knowledge of healthcare billing regulations, payer policies, and clinical trial reimbursement guidelines. Assist with the resolution of billing discrepancies related to clinical trial services. Provide training to research staff on coverage analysis and compliant billing practices.