RN, Medical Policy Coordinator

Blue Cross Blue Shield of Michigan•Detroit, MI

About The Position

The RN, Medical Policy Coordinator coordinates the development and maintenance of medical policies and benefit interpretations in accordance with BCN certificates, riders, waivers, statewide policies, and BCBSM policies and procedures. The role investigates new procedures, technologies, drugs, and devices; maintains clinical documentation regarding new technologies and treatment modalities, including BCN coverage positions; and communicates and educates team members, including physician advisors, about these developments and related policy and benefit determinations. The coordinator manages requests involving specified solid organ transplants, bone marrow transplants, and potentially experimental or investigational services. The role proactively evaluates new treatments and technologies for potential coverage determinations across lines of business, develops policies for committee review, and maintains documentation supporting policy and benefit interpretation decisions for internal and external communications. It also develops research resources, searches medical literature and other sources, and compiles evidence supporting determinations under applicable BCN, Blue Choice, and CMS guidelines. The position responds to inquiries from internal teams, other departments, and providers, coordinates benefit issues for committee agendas, and organizes materials for the Joint Uniform Medical Policy Committee, the BCN Medical Management Committee, and medical directors. It develops and maintains professional contacts within BCN, BCBSM, BCBSA, and external vendors. The coordinator reviews and documents case requests, prepares cases for medical director review, and coordinates claims review, including multi-line surgery claims, benefit-related issues, and claims requiring medical-record review. Other duties may be assigned by Care Management leadership.

Requirements

Current, valid Michigan Registered Nurse (RN) license.
Bachelor’s degree required; a nursing or other health care-related major is preferred. Alternatively, an associate’s degree or two years of full-time college credits may qualify with one year of utilization/quality management experience for each year toward the missing bachelor’s degree, in addition to the stated experience requirements.
Four years of broad clinical experience.
Three years of utilization management and/or quality management experience.
Excellent verbal and written communication skills.
Excellent organizational skills and ability to work independently as a self-starter while managing multiple projects and timelines, including planning and development.
Interpersonal skills to work as part of a team and interact with internal and external customers and all organizational levels.
Ability to work independently with minimal direction.
Problem-solving, research, analytical, and decision-making skills.
Intermediate knowledge of Microsoft Word.
Knowledge of current medical and clinical practices, including community standards of practice, and benefit determination related to medical treatment issues.

Nice To Haves

Bachelor’s degree major in nursing or another health care-related field.
Utilization management and/or quality management experience in a managed care environment.
Two years of experience in medical policy or benefit determinations.
Knowledge of Facets and CarePlanner.
Detailed knowledge of BCN policies and procedures and BCN Member Certificates, including riders, waivers, exclusions, and limitations.
Knowledge of CMS benefit guidelines.
Knowledge of BCN medical management processes, reimbursement policies, utilization management policies and procedures, and claims processing flow.
Knowledge of BCBSM medical policies and procedures, claims processing flow, and utilization management policies and procedures.
Knowledge of NCQA, CMS, and state and federal HMO regulations.
Technical writing skills.
Knowledge of Microsoft Excel and Access.

Responsibilities

Coordinate development and maintenance of medical policy and benefit interpretations in accordance with BCN and BCBSM policies, procedures, certificates, riders, and waivers.
Investigate new procedures, technologies, drugs, and devices, and maintain clinical documentation concerning new technologies, treatment modalities, and BCN coverage positions.
Communicate information about new technologies and treatment modalities to team members, including physician advisors, and provide related education.
Coordinate requests involving solid organ transplants other than kidney, skin, and cornea; bone marrow transplants; and potentially experimental or investigational services.
Identify and evaluate new treatments and technologies for potential coverage determinations by BCN and/or BCBSM across lines of business.
Develop policies for presentation to the Joint Uniform Medical Policy Committee or the BCN Medical Management Committee.
Maintain documentation supporting medical policy and benefit interpretation decisions, including material for internal and external communications.
Develop and maintain research resources, including sources such as the FDA, TEC, and BCBSA, to support technology assessments and medical policy development.
Research and compile documentation supporting medical policy determinations and benefit interpretations in accordance with applicable BCN, Blue Choice, and CMS guidelines.
Conduct internet and medical literature searches for medical policy, care management, quality management, pharmacy management, and other areas as needed.
Respond to inquiries from team members, other departments, and providers, supporting appropriate and consistent benefit interpretation.
Coordinate benefit issues with the committee chairperson for inclusion on Medical Management Committee agendas.
Collect and coordinate information for review by JUMP, the Medical Management Committee, and medical directors, including draft joint and BCN policies.
Develop and maintain contacts within BCN, BCBSM, BCBSA, and external vendors to support timely and consistent policy development and benefit interpretation.
Collect and review case documentation, prepare cases for BCN/BCBSM Medical Director review as indicated, and document cases according to established processes.
Review and coordinate claims, including multi-line surgery claims, benefit-related claims issues, and claims requiring medical-record review, to support prompt and accurate processing.
Perform other duties as assigned by Care Management leadership.