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 policy and benefit interpretation in accordance with BCN certificates, riders, waivers, statewide policies, and BCBSM policies and procedures. The role investigates new procedures, technologies, drugs, and devices and maintains clinical documentation about new technologies and treatment modalities, including BCN coverage positions. It communicates and educates team members, including physician advisors, about new technologies and BCN policy and benefit determinations. The coordinator manages requests involving solid organ transplants other than kidney, skin, and cornea; bone marrow transplants; and services that may be experimental or investigational. The role evaluates new treatment and technology documentation for potential coverage determinations across lines of business, develops policies for committee consideration, researches medical literature and other resources, supports consistent benefit interpretation, and coordinates case reviews and claims-related work.

Requirements

Registered nurse (RN) with a current, valid Michigan license.
Bachelor's degree required; a major in nursing or another health care-related field is preferred. Alternatively, an associate's degree or two years of full-time college credits plus one year of utilization/quality management experience for each year toward the bachelor's degree lacking, in addition to the experience requirements listed.
Four years of broad clinical experience.
Three years of utilization management and/or quality management experience; managed care experience is preferred.
Excellent verbal and written communication skills.
Excellent organizational skills and ability to self-start and handle multiple projects and timelines, including planning and development.
Excellent interpersonal skills, including ability to work on a team and interact with internal and external customers and all levels of the organization.
Ability to work independently with minimal direction.
Excellent 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 as related to medical treatment issues.

Nice To Haves

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 activities related to the development and maintenance of medical policy and benefit interpretation in accordance with BCN certificates, riders, waivers, statewide policies, and BCBSM policies and procedures.
Investigate new procedures, technologies, drugs, and devices and maintain clinical documentation about new technologies and treatment modalities, including BCN coverage positions.
Communicate and educate team members, including physician advisors, about new technologies, treatment modalities, drugs, and devices, with an emphasis on BCN policy and benefit determinations.
Coordinate requests related to solid organ transplants other than kidney, skin, and cornea; bone marrow transplants; and potentially experimental or investigational services.
Proactively identify and evaluate documentation on new treatments and technologies for potential coverage determinations by BCN and/or BCBSM across all lines of business.
Develop policies for new treatments or technologies for presentation to the Joint Uniform Medical Policy (JUMP) Committee or the BCN Medical Management Committee.
Maintain documentation supporting medical policy and benefit interpretation decisions, including documentation used in internal and external communications.
Develop and maintain resources for investigative and research activities, potentially including the FDA, TEC, and BCBSA, to support technology assessments and their application to medical policy.
Research and compile documentation supporting medical policy determinations and benefit interpretations in accordance with applicable certificates, riders, waivers, 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 and other departments, as well as complex inquiries from PCGs/PCPs, to ensure appropriate and consistent benefit interpretation.
Coordinate benefit issues with the committee chairperson so relevant issues are added to Medical Management Committee meeting agendas and benefit interpretation is consistent.
Collect and coordinate information for review by JUMP, the Medical Management Committee, and/or Medical Directors for medical policy determinations and benefit interpretation statements, including drafts of joint and/or BCN policies.
Develop and maintain a network of contacts within the BCN network, BCBSM, BCBSA, and external vendors to facilitate timely and consistent policy development and benefit interpretation.
Collect and review documentation related to case requests, including transplant and experimental/investigational requests.
Prepare cases for review by BCN/BCBSM Medical Directors 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.