Medical Policy Specialist II

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

About The Position

This position is responsible for the development and maintenance of Horizon Blue Cross and Blue Shield of New Jersey (HBCBSNJ) medical policy in conjunction with physician staff and the coordination of policy implementation with the Coding, Integration and NASCO/FACETS IT Teams including gathering and analyzing data to validate business impact of the policies. In addition, this position is responsible for coordinating UM Vendor activities related to the various UM Vendor Delegation Programs.

Requirements

High School Diploma/GED required.
Bachelor degree preferred or relevant experience in lieu of degree.
Require five (5) to seven (7) years clinical nursing/physician experience.
Require three (3) to five (5) years medical claims processing experience.
Require clinical research and policy development and maintenance experience.
Require data management (gathering and analysis) experience.
Require in depth knowledge of anatomy and physiology.
Require knowledge of health care delivery systems.
Require in depth knowledge of CPT, ICD-9, and HCPC coding structure.
Require working knowledge of medical policy processing and files.
Require ability to perform detailed analysis of medical information.
Require good oral and written communication skills.
Require good interpersonal skills.
Require good technical aptitude.
Require ability to organize, document and resolve issues independently.
Require discretion in the handling of confidential information.

Nice To Haves

Active Unrestricted NJ RN License or foreign-trained physician preferred.
Prefer good PC skills.

Responsibilities

Development of new and revision of existing Medical Policies.
Performs research of the medical literature and other reliable sources. Medical Societies, UpToDate, ClinicalTrials.gov, etc.
Monitors and incorporates Centers of Medicare and Medicaid (CMS) directives into the medical policy document and integration as appropriate.
Ensure that any related government and accreditation body regulations and directives are applied in the development, maintenance and integration of the medical policies as appropriate.
Obtains and analyses financial impact data regarding new policies when possible
Gathers, analyzes and presents data as required by the committees.
Presentation of the policies and their impact to the Clinical Policy Committee and its subcommittees.
Actively engages in the annual review of medical policies.
Actively participates in the weekly Policy Committee and subcommittee meetings.
Assigning policies and assisting other team members in the review of their assigned policies.
Ensures completion of medical policy updates in the medical policy database (EMM) and the corresponding medical policy portal display (MP Web page).
Collaborates with the Clinical Coding Team on setting appropriate code parameters based on available sources and clinical description of code.
Collaborates with the Clinical Coding Team, Policy Quality and Reporting Team, Medical Policy Implementation and the NASCO/FACETS IT Teams for the system integration of Horizon medical policies for commercial, Medicare and Medicaid lines of business.
Maintain Medical Policy resource data supportive of Plan policy.
Ensures the accuracy of the published policy or provider notifications in the HBCBSNJ provider portal.
Monitoring and resolution of inquiries to the Medical Policy Team mailboxes (internal and external).
Tracks policy status for NCQA and DOBI standards.
Monitoring the alignment, accuracy and timeliness of information in the Evidence Management Module/Medical Policy Platform and the Horizon Medical Policy Web Display page.
Tracking and completion of Vendor Program Change Control Forms (CCFs).
Review issues identified through retrospective utilization review and coordinate activity between Utilization Review/Medical Policy to effectively resolve.
Coordinates the review of overturn cases from appeals and IMEs for determination of the need for policy reevaluation and/or revision.
Collaborates with other staff in gathering from multiple sources, analyzing and presenting data to the subcommittees to establish the business impact of active medical policies and guide appropriate stakeholder decision making for policy maintenance and implementation
Responsible for the review, alignment and presentation of Vendor medical policies/clinical guidelines for the various UM Vendor Programs to the Clinical Policy Committee for approval and adoption.
Participate in special projects as directed by management to improve unit functioning and assist in meeting Plan goals.
Orient and train new team members.