Registered Nurse - Medical Policy Development/Research Specialist - Remote - AZ

Blue Cross Blue Shield of Arizona•Phoenix, AZ

1d•Remote

About The Position

Blue Cross Blue Shield of Arizona (AZ Blue) is seeking a Registered Nurse to join their Medical Policy Development/Research Specialist team. This is a remote position requiring residency and work to be performed within the State of Arizona. The primary purpose of this role is to perform medical technology research to support the Medical Director Staff and Medical Policy Panel in making decisions, ensuring that medical policies align with accepted medical practice standards. AZ Blue is committed to inspiring health and making it easy, offering a variety of health insurance products and services. They operate under a hybrid workforce strategy called Workability, which provides flexibility in how and where employees work. While most employees are hybrid, this specific role is classified as remote.

Requirements

2 year(s) of experience in clinical field of practice, health insurance, or other health care related field (All Levels)
1 year(s) of experience in medical policy and technology research field (Applies to Level 2)
2 year(s) of experience in medical policy and technology research field (Applies to Level 3)
Associate’s Degree in general field of study or Post High School Nursing Diploma or Certification (LPN only) from an approved program (Applies to All Levels)
Active, current, and unrestricted license to practice in the State of Arizona (a state in United States) as a health professional, including RN, LPN, LPT, LBSW, LMSW, or LCSW. (Applies to All Levels)
Residency within the State of Arizona is required for this remote position.

Nice To Haves

3 year(s) of experience in clinical field of practice, health insurance, or other health care related field (All Levels)
1 year(s) of experience in claims retrospective review, utilization management, case management, appeals and grievances or quality review field (All Levels)
Bachelor's Degree in Nursing or related field of study (Applies to All Levels)
Active, current, and unrestricted State of Arizona (a state in United States) license to practice as a Registered Nurse (Applies to All Levels)

Responsibilities

Perform medical technology research related to coverage guidelines and new technology and provide evaluation and summarization to Medical Director Staff and/or Medical Policy Panel.
Perform medical technology research as requested by other areas of BCBSAZ thru the Medical Policy Referral Form.
Develop and revise coverage guidelines and criteria as requested by management, Medical Director staff or Medical Policy Panel.
Communicate medical policy information in protocol format to all areas of BCBSAZ requiring this information.
Participate as a contributing member on the Medical Policy Panel providing medical policy issues for discussion and, as required, on the Clinical Coding Governance Committee (CCGC).
Maintain a thorough knowledge of all BCBSAZ medical coverage guidelines and other policies, such as BCBS Association Medical Policy Reference Manual, MCG care guidelines and/or Change Healthcare InterQual, and eviCore criteria.
From the direction of management, Medical Director staff or Medical Policy Panel, facilitate external consultant reviews concerning a coverage guideline or new technology.
Responsible for initiating the consultation and providing a summarization concerning the external review to the requestor.
Responsible for arrangements for appropriate reimbursement for the consultant’s review.
Communicate medical policy information in protocol format to healthcare providers upon request.
With moderate assistance and review by management, perform basic level of code review.
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations.
Maintain all standards in consideration of State, Federal, BCBSAZ and other accreditation requirements.
Working independently, recognizes necessity of an external consultant review concerning a coverage guideline or new technology, summarizing and reporting this information to management to facilitate the process as outlined for Level II.
With review by management, independently perform intermediate code review with knowledge and understanding of coverage guideline development/revisions with recommendations to the Clinical Coding Governance Committee (CCGC) for integration into benefit programming.
Responsible for the training, development and support of grade level I staff under an established training program.
With review by management, independently perform advanced code review with advanced knowledge and understanding of coverage guideline development/revisions with recommendations to the Clinical Coding Governance Committee (CCGC) for integration into benefit programming.
Working independently, initiate research from resource materials, e.g., clinical journals, periodicals, CMS (Medicare) guidelines and publications, BCBSA publications, other BCBS plans, and internet resources relating to technical, clinical and coverage guidelines, summarizing and reporting this information to management for further action.
Responsible for the training, development and support of grade level I and II staff under an established training program.
Assist manager with the implementation of daily operations with regard to guideline development and revisions, staff supervision, as well as necessary coaching to help each staff member reach personal, professional and department goals.
Assist manager with the coordination of all aspects of the Medical Policy Panel and Medical Director Meeting, including preparation, agenda and minutes.
Assist manager with the completion of the monthly, quarterly and annual reporting to Director.
Assist manager with the coordination of all aspects of the annual review(s) of MCG, eviCore and/or Change Healthcare InterQual criteria updates.
Assist manager with providing oversight to responsible staff for the monthly review of BCBS Association Medical Policy and Reference Manual (MPRM) updates.
Assist manager with providing the initial training and instruction for both professional and technical staff and designating the oversight of staff regarding training of new staff at the desk level of instruction/training.
Responsible for the training, development and support of grade level III staff under an established training program.
Conduct, and/or participate in internal committees that further the goals of BCBSAZ, the Health Services Division and the Medical Policy & Technology Department.
Working independently, perform advanced code review with advanced knowledge and understanding of coverage guideline development/revisions with recommendations to the Clinical Coding Governance Committee (CCGC) for integration into benefit programming.
Perform all other duties as assigned.