Resp & Qualifications
To research, develop, and coordinate the distribution and dissemination of medical and claims policies in support of corporate philosophy, provider and member contracts, and accepted standards of medical practice.
Under the general supervision of the Manager, Healthcare and Reimbursement Policy:
1. Consistently maintains an awareness of trends and current literature related to health and policy issues in the public and professional domains. Performs in-depth research on topics identified as actual or potential medical/claims policies/procedures. Critically analyzes current peer-reviewed articles and other pertinent sources to determine its appropriateness in support of and inclusion in policies. Assesses supporting data and communicates impact of information on company business or medical policy. Ensures that current and accurate sources are documented utilizing the approved format.
2. Writes evidenced-based corporate medical policies, administrative policies, operating procedures and/or claims adjudication policies in relation to legislative mandates, new technology assessments, contractual provisions, corporate philosophy, and accepted standards of medical practice in order for them to be applied uniformly and consistently across all lines of CareFirst business. Participates in critically analyzing new and existing medical technologies, including performing in-depth research, evaluating literature, and documenting and communicating impact of results in collaboration with the Coordinator, Technology Assessment. Maintains the on-line Technology Assessment reference database in the absence of the Technology Assessment Coordinator. Collaborates with Manager and Business Analysts to ensure that policies and procedures are reviewed and approved by appropriate individuals/groups. Submits reports regarding activities such as reviews, revisions, and new policies.
3. Researches and writes Issue Papers (i.e., analysis, impact, recommendations) related to high-impact policy and/or benefit issues. Coordinates cost/benefit analyses if necessary. Presents issue and makes recommendations to Vice President, Chief Medical Office or the designee for final decision. Collaborates with Medical Directors, Legal, and Contracting and other departments or Divisions throughout the organization as necessary.
4. Maintains the Medical Policy Reference Manual (MPRM) including resource files and publications. Ensures dissemination of policies and procedures to and from the Medical Policy Implementation Team and to other appropriate departments. Ensures maintenance and accuracy of the on-line versions of the MPRM. Ensures that quality controls and contingency systems are always in place to provide access to accurate medical policies.
5. Prepares and submits monthly/quarterly/annual reports regarding activities such as reviews, revisions, new policies, etc., as required, to Medical Affairs Division and CEO. Provides consultation and educational programs to internal and external customers related to medical policy development and interpretation, including but not limited to in-depth research (i.e., claims adjudication edits, CPT/HCPCS coding), and developing departmental policies and standard operating procedures. Consults, collaborates with, and provide information regarding medical policies to Medical Review and Clinical Appeals and other clinical areas within Health Services, as needed. Writes articles for inclusion in provider or member newsletters. Identifies actual or potential issues for audit/investigation and refers to appropriate department. Serves as a liaison between the provider community and CareFirst. Represents the Health Care Policy Department on various committees and task forces as required including the Legislative and Government Mandates workgroups. Mentors and assists with the orientation of new hires. Performs other duties at the request of management commensurate with the position.
• RN or comparable clinical licensure such as a PA (Physician’s Assistant)
• If RN, must have BSN or related bachelor’s degree. In lieu of Bachelor’s degree, must have 4 years of related experience.
• Coursework or experience in basic research methodologies and research data interpretation.
• A minimum of 5 years varied clinical experience in a health care setting.
• Must demonstrate knowledge and competency in all types of medical necessity decisions including various places of service and provider types and experience with policy and procedure development in the health setting.
• Professional coding certifications by a national organization (i.e., AAPC, or AHIMA) within the first year of employment.
• Proven experience with research methodologies and research data interpretation.
• Working knowledge of current standards of medical practice, insurance benefit structures and interpretation, and managed care principles.
• Proficiency in Microsoft Office Suite and web-based tools.
• Must demonstrate excellent analytical, oral and written communication skills.
• Must be proficient in writing original, complex, and technical corporate Medical Policies.
• Knowledge of reporting and complex data analysis.
• Must be a team player with the ability to facilitate projects and groups and work independently with minimal supervision.
• Must be knowledgeable of CPT, HCPCS, and ICD-10 coding systems.
• Knowledge of CareFirst products and services and benefit administration.
• Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Master’s degree or PhD. in a related health care discipline. Coursework in technical writing and statistics.
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 5.4.21
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship