Medical Policy Specialist I

Horizon Blue Cross Blue Shield of New Jersey•Hopewell, NJ

1d•$87,300 - $119,070•Onsite

About The Position

This position is responsible for research and development of Plan medical policy in conjunction with medical director and/or manager. This includes coordination of policy implementation and dissemination of Medical Policy updates across the enterprise. In addition, this position must review annual code changes and determine the impact on medical policies. This position will also serve as a Subject Matter Expert on medical policy to the enterprise.

Requirements

High School Diploma/GED required.
Bachelor degree preferred or relevant experience in lieu of degree.
Requires minimum three (3) years clinical nursing/physician experience.
Requires minimum three (3) years medical claims processing experience.
Requires a Registered Nurse (RN) license or foreign trained physician.
Requires in depth knowledge of anatomy and physiology.
Requires knowledge of health care delivery systems.
Requires in depth knowledge of CPT, ICD-9/10, and HCPC coding structure.
Requires working knowledge of medical policy processing and files.
Must have effective verbal and written communication skills and demonstrate the ability to work well within a team.
Must have demonstrated ability to deliver highly technical information to less technical individuals.
Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.
Must have proven time management skills.
Proven ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required.
Demonstrated ability to work in a production focused environment.
Proven ability to exercise sound judgment and strong problem solving skills.
Proven ability to ask probing questions and obtain thorough and relevant information.
Must be client service focused with effective ability to empathize.
Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint), Lotus Notes and Outlook; should be knowledgeable in the use of intranet and internet applications.

Responsibilities

Review and analyze various sources of clinical and health related technology to keep abreast of new medical technology requiring development of Plan policy.
Actively participates in Medical Policy Committees and related functions.
Advises the implementation of Medical Policy in cooperation with the Medical Policy Integration team.
Maintain Medical Policy resource data supportive of Plan policy.
Review and update annually all existing Horizon medical policies.
Review issues identified through retrospective utilization review and coordinate activity with Utilization Review/Medical Policy to effectively resolve.
Assists as needed in the review and analysis of various sources of clinical and health related technology to inform the development of Plan policy.
Assists as needed in the research and development of Plan medical policy in conjunction with the medical director and/or manager.
Demonstrates knowledge and understanding of the laws regulations and policies that pertain to the organization unit's business and conforms to these laws, regulations and policies in carrying out the accountabilities of the job.
Participates in special projects as directed by management to improve unit functioning and assist in meeting Plan goals.