Company :Highmark Health
Job Description :
This job owns the full-cycle commercial medical policies, both developed internally and by vendors. This includes the writing of clinical criteria based on research, engagement of non-clinical team members for operational guidelines, and ownership of the publishing process. The incumbent must have an understanding of medical coding (ICD-10, CPT, HCPS) as medical coding based off of policy criteria falls in their scope. In addition to developing new policies, the incumbent ensures all existing medical policies, in their scope, are up to date which may involve revisions in response to escalated inquiries brought forward by internal/external partners. Conducts peer reviews as part of the quality review process. In addition to policy ownership, the incumbent participates on various work-groups and sub-committees as clinical leads/experts. Trains and orients new staff to the department and policy procedures, and mentors new team members. Serves as a liasion between other departments and vendors as required.
- Full-cycle ownership of the commercial medical policy creation process including writing clinical criteria and oversight/ownership of the clinical presentations to committees and publication process for internally owned and vendor owned policies. Engage other departments, team members, and vendors to assist with research, the development and communication of operational guidelines, and aspects of publication.
- Provide clinical guidance to non-clinical team. This may include those who own Medicare Advantage policy owners, and those who support the commercial policy group.
- Address escalated policy inquiries that need clinical expertise. This may include updating/revising existing commercial policies.
- Other duties as assigned.
- Bachelor's degree in Nursing
- 6 years of health care experience or alternative clinical education can be substituted in lieu of bachelor's degree.
- 3 - 5 years of Healthcare Experience
- 1 - 3 years of Medical Policy
- 1 - 3 years of Medical Coding
LICENSES OR CERTIFICATIONS
- Registered Nurse OR Certified Registered Nurse Practitioner
- Medical Coding Certification
- 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 job 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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