Medical Policy Consultant Senior - Medicare / Government Programs

Industry: Accounting, Finance & Insurance


5 - 7 years

Posted 275 days ago

This job is no longer available.

Description Summary

This position is a key member of the policy implementation team at Blue Cross, with responsibility for the Medicare Advantage line of business. Important policy resources for implementation include but are not limited to National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), McKesson InterQual criteria and Blue Cross Blue Shield of Minnesota medical policies. The incumbent will be responsible for ensuring that new or revised medical policies and guidance documents are circulated to internal stakeholders of the company before final implementation. Additional responsibilities include build out of clinical rules and survey criteria sets to support auto-authorizations through the Availity/BlueCore applications.

The incumbent will be part of a team that ensures consistent integration of policies on all systems to enable accurate claims processing and reporting. Responsibilities will include reviewing and applying new codes to the medical policies, developing quality improvement processes for medical policy implementation, and assisting with data reporting needs, as they pertain to the policy implementation process. The incumbent will also organize communication on medical policy changes and serve as a liaison within the Government Programs division, for discussion and communication of medical policy issues among key stakeholders. The Senior Medical Policy Consultant serves as a key resource for the Medicare Advantage team as well as other members of the Medical Policy team.


  1. Provide implementation input on clinical criteria sets for the Medicare Advantage program and present this information to relevant oversight committees:

    1. Government Program committees including the PAMMP meetings and Rules meetings.
    2. Medical and Behavioral Health Policy Committee.
    3. Coverage Committee.
    4. Operational workgroups and committees, as assigned.
  2. Prepare final policy documents and tools for implementation.
  3. Ensure that implemented medical policies are integrated with all systems to enable accurate claims processing.
  4. Ensure that changes in the medical policy positions for Medicare Advantage are communicated to all related business areas.  
  5. Research and apply appropriate and regular updates in CPT, HCPCS, and ICD medical coding to the medical policies.
  6. Maintain Blue Cross's intranet and internet medical policy databases for Medicare Advantage with current policy decisions and coding.
  7. Build out of clinical rules and survey questionnaires to support auto-authorizations of Medicare Advantage clinical criteria sets through the Availity/BlueCore applications.
  8. Produce standard reports and assist in the analysis and impact of these reports as they relate to policy implementation process. This will require training in several Blue Cross systems such as the utilization management platform, claims processing application and others as necessary.
  9. Serve as a liaison to other divisions (e.g., expanded Medicare Advantage Team, Network Management, Account Management, and Service) for medical policy issues on government programs.
  10. Research issues on an ad hoc basis to determine coverage status of other payers and FDA approval status; this may also require limited research of evidence-based literature.
  11. Lead work groups and projects that support the Medicare Advantage Program and Medical Policy Department.  
  12. Serve as a subject matter expert on medical policy implementation and claims processing for Medicare Advantage.


  • Bachelor's degree in a health-related field, such as nursing and 6 years work experience in a health plan or 10 years of experience in lieu of Bachelor's degree.
  • Ability to apply critical thinking skills to medical policy interpretation and implementation.
  • Ability to work independently; well-organized and able to set priorities with minimal direction
  • Ability to effectively communicate both verbally and in writing.
  • Strong PC skills; Excel, PowerPoint, Visio, Word, and internet based programs.
  • Ability to develop and work on several projects at one time in a fast paced environment.
  • Ability to maintain relationships with internal and external stakeholders, clinicians, and others.
  • Project managementexperience.
  • Demonstrated positive professionalism in all work-related behaviors as demonstrated by adaptability, contributing to team success, customer focus, skillful communication, and efficiently managing work.
  • Experiencesharing best practices and skills with peers and team as a whole.

Preferred Requirements

  • Masters degree in a health-related field, such as nursing.
  • Experience in use of medical code sets (CPT; ICD; HCPCS).
  • Prior work or strong interest in government programs (Medicare and/or Medicaid).


Coding Certification: 

CPC: (Certified Professional Coder)

COC: (Certified Outpatient Coder)

CPC-P: (Certified Professional Coder-Payer)

CPMA: (Certified Professional Medical Auditor)

CRC: (Certified Risk Adjustment Coder)

CCS-P: (Certified Coding Specialist Physician Based)

CCA: (Certified Coding Associate)