Medical Policy Analyst

Blue Cross & Blue Shield of Rhode Island•Providence, RI

1d•$73,600 - $110,400•Hybrid

About The Position

Develop and evaluate the effectiveness of company medical and administrative policies. Research and develop new policies as well as changes to existing policies on a regular basis. Perform industry evaluations/benchmarking of BCBSRI policies to industry standards. Work with other internal business and clinical associates and medical directors in the development and approval of both new, and updates to, existing policies. Ensure internal training materials and external provider documentation is consistent with company policies and state and federal guidelines and/or accreditation requirements. Coordinate and organize quarterly new code releases from the American Medical Association and Centers for Medicare and Medicaid Services.

Requirements

Bachelor’s Degree in Nursing, Business Administration, Healthcare Services or related field, or an equivalent combination of education and experience
Three to five years of experience in medical policy review, quality management or an analytical discipline
Certified Professional Coder (CPC) Certification
Proficiency with Microsoft Suite of products (i.e., Word, Excel, PPT, etc.)
Proficiency in web-based searching and CMS website navigation
Medical policy and benefit knowledge
Knowledge of medical terminology and claims payment policies including applicable coding methodology
Advanced analytical skills, with the ability to interpret and synthesize complex data sets
Good business acumen and political savvy
Knowledge of business process improvement techniques and strategies
Ability to work independently or as an active member of a team
Accurate and precise attention to detail
Ability to multitask, prioritize, and manage time efficiently
Excellent verbal and written communications skills
Negotiation skills
Presentation skills
Decision-making skills
Problem-solving skills
Ability to interface with employees at all levels
Ability to effectively navigate ambiguous situations with limited direction
Excellent organizational skills and ability to successfully prioritize multiple tasks
Ability to handle multiple priorities/projects

Nice To Haves

Contract knowledge and knowledge of provider risk arrangements
Knowledge of managed benefits strategies, utilization review techniques, healthcare financing and delivery

Responsibilities

Evaluate effectiveness of company medical and administrative; serve as internal and external contact for inquiries related to policies.
Work closely with medical staff to review existing policies and develop recommendations for new policies.
Ensure adherence to corporate timelines and quality standards for creating new policies and reviews of existing policies, while adhering to applicable state and federal guidelines, accreditation agencies (e.g. NCQA, as well as Centers for Medicare and Medicaid Services (CMS)) requirements and guidance.
Direct internal areas in the development and implementation of policies.
Provide education to staff regarding policy administration.
Administer research for quarterly new code releases and coordinate workgroups of stakeholders to obtain coverage determinations necessary for implementation of code sets.
Participate in department initiatives and projects.
Serve as department representative and participate on projects related to company medical, administrative, and some reimbursement policies.
Maintain provider manuals and internal training materials; ensure materials are consistent with policies and state and federal guidelines.
Establish criteria for the financial impact analysis of policies; collaborate with internal areas to obtain financial data.
Participate in the testing and creation of business requirements for the system request process.
Monitor status reports to ensure timely implementation and communication (internal and external) of system changes.
Perform other duties as assigned.