Company :Highmark Health
Job Description :
This job prepares market level analysis, conducts medical policy research, pulls journals, and checks mandates for the non-clinical aspect of the commercial policy development. The incumbent owns the development of the operational guidelines, and works with internal Health Plan partners to communicate the guidelines to ensure claims are processed accurately. In addition to the commercial policy responsibilities, the incumbent has ownership of the Medicare Advantage policies. Regularly interprets updates from CMS against existing policies and determines whether changes are required. If changes are necessary, updates the policies per the CMS guidelines and publishes the updated policies. The incumbent completes project work and conducts peer reviews to check for grammar and accuracy as part of the quality review process. May conduct analyses on policies to track members impacted and cost, as well as conduct research on claims that may in turn trigger policy changes/updates.
- Conduct full-cycle ownership of the Medicare Advantage policy update/revision process including monitoring incoming notifications from CMS and conducting external research. Interpret guidelines from CMS compared to existing policies, and determine whether changes are required. If changes are required, update policies and revise accordingly.
- Support the Medical Policy Clinician team on the development and revision of commercial medical policies. This includes conducting research, preparing market level analysis, pulling journals, and checking mandates. It also requires developing and maintaining operational guidelines for commercial policies and translates them to other Plan teams within the Organization to ensure claims are processed accordingly.
- Peer review for quality assurance
- Conduct analysis and claims research to understand whether policies may require updates.
- Other duties as assigned.
- Bachelor's Degree in Business Administration/Management, Communications , Studies/Speech Communication and Rhetoric, English, Health Administration or Journalism
- 6 years of health care experience can be substituted in lieu of education.
- 1 - 3 years of Healthcare Industry Experience
- 0 - 1 years of Medical Policy Experience
- 0 - 1 Medical Coding Experience
LICENSES OR CERTIFICATIONS
- Oral & Written Communication Skills
- Telephone Skills
- Problem Solving & Decision Making
- Healthcare Industry
- Health Insurance
Language Requirement (other than English)
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
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.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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