Medical Policy Analyst (Remote) Id-3401
Job Description
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.
We are looking for an experienced professional to live and work remotely from within the greater Baltimore/Washington 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:
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:
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:
Knowledge, Skills and Abilities (KSAs)
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.
We are looking for an experienced professional to live and work remotely from within the greater Baltimore/Washington 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:
- RN - Registered Nurse - State Licensure And/or Compact State Licensure Registered Nurse (RN) Required.
- Certified Coder (CCS or CPC)-AHIMA or AAPC AAPC Certified Professional Coder (CPC) within 1 Year Required.
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.
