Medical Policy Nurse - Novitas Solutions

GuideWell Source • Remote, OH

3h • Remote

About The Position

This position is responsible for the development and maintenance of Local Coverage Determinations (LCDs) and Local Coverage Articles (Articles) in accordance with the CMS regulations and requirements and has a direct impact in ensuring access to care for Medicare beneficiaries, ensuring claims are paid correctly, and in safeguarding the Medicare trust fund. The company aims to improve the lives of nearly 12 million Medicare beneficiaries and 700,000 healthcare providers, striving to create a better health experience for all consumers.

Requirements

• High School Diploma or GED
• 3 years' related work experience
• 2 years of Medicare experience
• 1 year of health insurance coding (e.g., ICD-10, CPT/HCPCS) experience
• Proficient in research of the CMS Internet-Only manual (IOM) and national and local coverage decisions
• Proficient in MS Office applications and Internet research
• Comprehensive knowledge of medical, surgical and diagnostic procedures and terminology
• Excellent written and oral communication skills
• Ability to communicate with confidence with other medical professionals, Medical Societies, Medicare providers, CMS and Contractor Advisory Committee (CAC) members
• Professional demeanor and positive approach to work
• Excellent planning, organizing, time and work management skills
• Ability to travel
• Valid unrestricted Registered Nurse (RN) license
• Must have lived in the United States for a minimum of three (3) years out of the last five (5) years.
• Must undergo a pre-employment Background Investigation, Drug Screen, and Identity Proofing.
• Must have access to a current and unrestricted REAL ID, U.S. Passport, U.S. Passport Card, Foreign Passport, or U.S. Permanent Residency Documents.

Nice To Haves

• Bachelor's degree in Nursing
• 5 or more years of clinical experience as a Registered Nurse
• 3 or more years of Medicare experience
• 3 or more years of experience in Health or Business Administration
• 3 or more years of health insurance experience in operations, claims review, case review, education, and/or medical and payment policy
• 3 or more years of health insurance coding (e.g. ICD-10-CM, CPT/HCPCS)
• Certified Professional Coder (CPC) certification/credential

Responsibilities

• Development and maintenance of new LCDs and Articles, including thorough review, analysis, and summary of claims data, pertinent CMS instruction, available evidence (published medical literature, discussion with Contractor Advisory Committee (CAC) members, subject matter experts (SMEs), Medicare providers, etc.), and correct coding and billing requirements.
• Review of Reconsideration Requests and completion of appropriate resulting LCD revisions.
• Annual and other mandatory updates (e.g., diagnosis and procedure codes, Change Requests, etc.).
• Development and maintenance of accessible electronic LCD and Article files.
• Participation in the formal, external Open Meetings and CAC meetings including creation and presentation of information specific to assigned LCDs.
• Review and revision of departmental procedures related to LCD development and revisions.
• Serves as point of contact for internal operations regarding medical coverage and coding questions.
• Collaborates with edit team to ensure appropriate edits are created in keeping with the LCD instruction.
• Serves as SME for assigned LCDs and Articles and interfaces with technical, professional, and clinical personnel; routinely interacting with all levels of staff in the company, including the Executive Medical Directors, as well as other senior leaders.
• Attends regularly scheduled internal meetings to ensure adequate information sharing and education as appropriate throughout the company regarding LCDs and Articles.
• Accountable for regular and ongoing communication with external customers, including but not limited to, CMS, local and national medical societies/associations, stakeholders, other professional organizations, and Medicare providers, to ensure adequate information sharing and education regarding LCDs and Articles.
• Routinely and proactively collaborates with team members including the CMDs, senior leadership, and operational leads as necessary to identify and implement improvements related to the policy development process.
• Performs other duties as the supervisor may, from time to time, deem necessary.

Benefits

• Medical, dental, vision, life and supplemental insurance plans effective the first day of the month following date of hire
• Short- and long-term disability benefits
• 401(k) plan with company match and immediate vesting
• Free telehealth benefits
• Free gym memberships
• Employee Incentive Plan
• Employee Assistance Program
• Rewards and Recognition Programs
• Paid Time Off and Paid Sick Leave

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED