MMM Holdings, LLC is a company that provides Medicare Advantage and Medicaid plans in Puerto Rico. Currently, MMM Holdings, LLC operates in Puerto Rico under Elevance Health, Inc. a leading health company dedicated to improving the quality of life of communities in the United States. Through its affiliated companies, they serve more than 118 million people.

Medical Policy Analyst

Location: This position will work on-site on Torre Chardon Building, Chardon Ave. 350 Suite 500 San Juan, Puerto Rico.

Schedule: This position will work a 1st Shift from 8:00 am- 5:00 pm Monday thru Friday. Additional hours or days may be required based on operational needs.

The Medical Policy Analyst is responsible for medical research and developing criteria for medical policies to be used by review, utilization, and case management nurses.

How you will make an impact

Primary duties may include, but are not limited to:

• Review existing policies on a quarterly basis to ensure policy is update accordingly with latest version of the regulatory agency or other source as mentioned above.

• Actively collaborates in the evaluation of new incoming CMS medical policies (NCD, LCD, Medicare manual and or Articles changes).

• Support the clinical operations in the regulatory process; make all guidelines public. These include but is not limited to removal, replacement and or a new publication of policies.

• Researches and evaluates medical claim issues against local and national Medicare policy guidelines.

• Reviews new and updated codes for accuracy and consistency.

• Researches relevant studies and reviews articles for development of local medical review policies and for responses to inquiries from providers.

• Works with Medical Directors on development of local medical review policies.

• Assists operations by reviewing complex and non-standard type of claims as related to a policy.

• Codes changes into clinical systems using national coding structure for processing accuracy and clinical appropriateness once medical policy has been established by physician plan committee.

• Serves as a liaison to business units for correct coding of clinical codes.

• Researches questions and issues from internal physicians and nurses as they relate to developed medical policies.

• Responds to internal and external requests that seek written clarification of a general or specific policy question.

• The response may be reiteration of an established policy, a redefinition of the current policy, or research to determine a new or revised policy.

Minimum Requirements:

• Requires a BA/BS degree and a minimum of 2 years related experience including clinical experience and may include operations experience; or any combination of education and experience which would provide an equivalent background.

• Typically requires active state RN license.

Preferred Skills, Capabilities, and Experiences:

• Bachelor's degree in a clinical healthcare discipline or nursing degree preferred.

• Clinical licensure (PR registered nursing license) preferred.

• Travels to worksite and other locations as necessary.

• Fully Bilingual (English & Spanish). Must be able to write, read and speak both languages in a proficiency level.