Resp & Qualifications

PURPOSE:

In collaboration with the Medical Director, the Senior Medical Policy Analyst will research, analyze, evaluate, revise, and develop medical policies and operating procedures to support the corporate philosophy, provider and member contracts, and an accepted standard of medical practice. The Senior Medical Policy Analyst will work closely with organizational teams to ensure medical policy and operating procedures are accurately operationalized for optimal claims adjudication and utilization management. We are looking for an experienced professional to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities.

ESSENTIAL FUNCTIONS:

• Consistently maintains an awareness of trends and current literature related to health and policy issues in the public and professional domains. In collaboration with the Medical Director, performs in-depth research on topics identified for the development of potential medical policies. Critically research clinical evidence-based research resources, as well as analyze quantitative and qualitative claims utilization data within the scope of research to determine its appropriateness for support of and inclusion of criteria in existing medical policies and operating procedures.

• Writes evidenced-based medical policies and operating procedures to support compliance with legislative mandates, new technology assessments, contractual provisions, corporate philosophy, and accepted standards of medical practice in order to be applied uniformly and consistently by across all lines of business, as deemed appropriate by the Medical Director.

• Lead the discussion during the Medical Policy Committee meetings by articulating the clinical scope and conveying the clinical guidance associated with the revision and development of medical policies and operating procedures. Collaborate with organizational operations teams to assist with operationalizing the medical policy and operating procedures based on the clinical and legislative guidance outlined through clinical editing and benefit configuration.

• Maintains the Medical Policy Reference Manual (MPRM) including resource files and publications. Ensures dissemination of medical policies and operating procedures to internal and external customers according to CareFirst application protocol and regulatory standards.

• Supports and mentors less experienced and/or new team members.

QUALIFICATIONS:

Education Level: Bachelor's Degree in Nursing, Public Health, English or related field directly related to the position OR in lieu of a bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Licenses/Certifications:

• RN - Registered Nurse - State Licensure And/or Compact State Licensure Registered Nurse (RN) Upon Hire Required and

• Certified Coder (CCS or CPC)-AHIMA or AAPC Certified Professional Coder (CPC) within 1 Year Required

Experience: 5 years Clinical experience within the field of Medical Surgical, Mental Health, Durable Medical Equipment, and/or Utilization Management, including significant experience in research methodology and systematic evaluation of medical literature and translation of evidence into policy in a healthcare setting

Preferred Qualifications:

• Masters degree in nursing or related health care discipline.

• Experience with a health care payer organization with a working knowledge of scientific terminology as well as strong medical and research concepts experience to include dissemination of policy-related materials such as policy issue briefs, comment letters, and advocacy documents.

Knowledge, Skills and Abilities (KSAs)

• Self-motivated, able to take initiative, and work independently with minimal oversight to meet timelines, strong follow-through skills and a solutions-oriented attitude. Ability to analyze, organize and prioritize work while meeting multiple deadlines.

• Ability to analyze essential facts, make timely and sound decisions, make recommendations and resolve performance and job-related issues. Demonstrated desire to share knowledge and work as a team.

• Excellent written and verbal communication skills with the ability to consistently demonstrate effective questioning techniques and the ability to engage learners and transfer knowledge.

• Knowledge of NCQA requirements of utilization review, Case Management standards and guidelines, appeal rights and responsibilities, and Regulatory requirements at the state and federal level for health care administration and Carrier standards.

• Working knowledge of medical insurance and managed care principles and knowledgeable of CPT and ICD-10 coding systems. Knowledge of all types of medical necessity decisions including various places of service and provider types.

• Advanced knowledge in the use of web-based technology and Microsoft Office applications such as Word, Excel, and Power Point Advanced. Proficient with database entry and query software.

• 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 positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range: $69,768 - $138,567

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

Medical Policy

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.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

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.

PHYSICAL DEMANDS:

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

#LI-NH2

REQNUMBER: 19523