Medical Policy Nurse - First Coast Service Options

GuideWell Source

9d • Remote

About The Position

Are you interested in joining a team of experienced healthcare experts and have
the ability to shape and transform the healthcare delivery system? At our family
of companies, everything we do is to help improve the lives of the nearly 12
million Medicare beneficiaries we serve and 700,000 health care providers who
care for them. It is our goal to help create a better health experience for all
consumers. Join our winning culture and help transform Medicare for the millions
of people who rely on its services.

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.

Requirements

• High School Diploma or GED
• 3 years' related work experience; this includes 2 years of Medicare experience and 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

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 LCDs and Articles
• 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