Resp & Qualifications

PURPOSE:
In collaboration with the Medical Director, the Medical Policy Analyst will research, analyze, evaluate, and revise medical policies and operating procedures to support the corporate philosophy, provider and member contracts, and accepted standard of medical practice. 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:

• Performs in-depth research on medical topics identified in existing medical policies and operating procedures scheduled for revision or updates based upon changes in the standard of care. Evaluates current peer-reviewed articles and other literature to determine its appropriateness of clinical guidance and mandated legislation in support of and inclusion in policies.
• In collaboration with the Medical Director, revise evidenced-based medical policies and operating procedures in compliance with legislative mandates, contractual provisions, corporate philosophy, and accepted standards of medical practice in order for them to be applied uniformly and consistently across all lines of business.
• 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.

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 Required:

• RN - Registered Nurse - State Licensure And/or Compact State Licensure Registered Nurse (RN).
• Certified Coder (CCS or CPC)-AHIMA or AAPC Certified Professional Coder (CPC) within 1 Year.

Experience:

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

Preferred Qualifications:

• Certified Professional Coder (CPC).

Knowledge, Skills and Abilities (KSAs)

• Ability to analyze essential facts, make timely and sound decisions, resolve performance and job-related issues. Demonstrated desire to share knowledge and work as a team.
• Excellent written and verbal communication skills, and the ability to present to internal clients of all levels.
• 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.
• Knowledge of principles, practices, evidence-based guidelines and standardized processes and procedures for evaluating medical support operations business practices.
• 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: $64,224 - $127,556

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

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