JOB SUMMARYThis job is responsible for medical research and developing utilization management pre-certification criteria for medical policies to be used by review, utilization, and case management nurses. Code changes into claims systems using national coding structure for processing accuracy and clinical appropriateness once medical policy has been established. Serves as a liaison to business units for correct coding of claims. Researches questions and issues from internal physicians and nurses as they related to development of medical policies.
ESSENTIAL RESPONSIBILITIES- Responsible for the research, analysis, development, maintenance, coordination, and documentation of medical policy for the Organization's entire Commercial and Medicare Advantage lines of business and all products.
- Accountable for coordinating and ensuring that the appropriate system changes are implemented in concert with policy development and revisions.
- Responsible for reviewing and analyzing all new, revised and deleted procedure codes published quarterly by the Centers for Medicare and Medicaid Services, the Blue Cross and Blue Shield Association, and the American Medical Association.
- Evaluation of potential impacts to medical policy and initiates applicable policy revisions.
- Coordinate database functions and policy issues with internal departments regarding Health Care Code System (HCCS) functions and policy issues.
- Review the International Classification for Diseases, (ICD-9, ICD-10) diagnosis code update for potential impacts to the database functions and policy issues.
- Responsible for all coordination's necessary related to policy maintenance and evaluates its impact to policy application and claims adjudication.
- Review and comment on all policy circulations within the department.
- Review all policy drafts for accuracy and respond appropriately to the author of the policy.
- Research inquiries and make policy decisions and/or recommendations to management.
- Respond to inquiries from both internal and external sources. Inquiries may require extensive research. Must be able to explain and support the rationale for the policy position in order to respond to physician inquiries, internal inquiries, legal depositions, and vendors.
- Research, develop and document topics for presentation (The Organization's Clinical Policy Management Committee (CPMC) or specialty Subcommittee). These evaluations require detailed analysis and interpretation of highly technical literature and clinical publications. A major responsibility involves the use of advanced research/writing/critical thinking skills to compile these extensive summaries for committee review.
- Review procedures and/or devices identified as potentially experimental.
- Periodically review all procedures that are currently classified as experimental/investigational and make a recommendation whether to retain the investigational status to management.
- Review new and revised BCBSA medical policies.
- Evaluate and compare all new and revised BCBSA medical policy bulletins to the Organization's medical policies. Make recommendations to management concerning the adoption of the BCBSA new policies or revisions.
- Other duties as assigned or requested.
QUALIFICATIONSMinimum- Bachelor's degree or clinical license/certification in lieu of bachelor's degree
- 5-10 years of relevant, progressive experience in the area of specialization
- Experience with medical policy development, contractual provisions, commercial claims and/or medical/surgical products or Medicare Advantage or Medicare Fee for Service program coverage, the Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD-9, ICD-10) information, project management, and Highmark claims processing requirements, and pricing mechanisms.
Preferred - Registered Nurse (RN), Licensed Practical Nurse (LPN), Certified Registered Nurse Practitioner (CRNP)
- Certified Professional Coder
- Experience in researching and interpreting clinical literature.
- Well-developed computer and clinical research experience
- Knowledge of the OSCAR claims processing system
Knowledge, Skills and Abilities - Experience with a PC and common software applications to include Web research Ability to analyze CMS documents such as transmittals and the Federal Register.
- Excellent verbal and written communication skills
- Independent assessment and excellent time management skills; multi-tasking accountability.
- Well-developed computer and clinical research experience
- Knowledge of the OSCAR claims processing system
SCOPE OF RESPONSIBILITY Does this role supervise/manage other employees?
No
WORK ENVIRONMENTIs Travel Required?
No
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum:$68,400.00
Pay Range Maximum:$105,900.00
Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
