Sr. Medical Policy Developer

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The Role

The Sr. Medical Policy Developer reports to the leader of Medical Policy Administration and is primarily responsible for creating and revising custom medical policies using InterQual as well as creating policies not using InterQual. This includes working as an individual contributor and collaborating with other departments, external stakeholders, and team members to support Medical Policy Administration.  This role requires proficiency in clinical writing, critical thinking skills and coding skills.

This position is eligible for the Flex persona. Local candidates are required to work from the Hingham office 2X per month. 

Key Responsibilities

• Utilizes clinical knowledge to create custom questionnaires based on medical policy guidelines and input into InterQual.
• Revises and maintains customized medical policies in InterQual.  This includes but not limited to criteria and code changes.
• Appropriately applies procedural and diagnostic coding (CPT, HCPCS, and ICD) to policy criteria with an understanding of the impact on policy enforcement.
• Actively participates in testing and validation of customized medical policies in InterQual.
• Works with system users to ensure consistent application and implementation of policies.
• Serves as a clinical consultant for the annual InterQual criteria and identifies any changes.  Presents changes to Medical Directors for approval as needed.
• Facilitates meetings with external physicians as needed.
• Attends the Association monthly Medical Policy Group meetings and keeps the team informed of policy changes by documenting minutes and tracking monthly changes.
• Creates monthly Medical Policy Announcement table.
• Represents Medical Policy Administration in various divisional and interdepartmental meetings.
• Responsible for updating/creating medical policies not in InterQual as needed.
• Responds to internal and external clinical mailbox inquiries from local physicians and clinical directors regarding policy content and rationales, as well as analysis and responses for industry representatives seeking coverage for advancing medical technologies as needed.
• Research clinical content (papers, PubMed, etc), document findings and provide recommendations on research outcome as needed.
• Conducts comparative market analysis for coverage positions, analyzing utilization, volume, and data trends as needed.
• Other duties as assigned.

Qualifications

• RN or PA-C required
• CPC required or desire to become certified
• BSN preferred
• Proficient in medical writing/clinical documentation
• Experience using InterQual preferred
• Strong Computer Skills. Proficient with Windows applications.
• Strong planning, organization and time management including the ability to meet deadlines, problem solve, and manage multiple competing priorities
• Demonstrated critical thinking and analytical skills
• Ability to work effectively individually and as part of a collaborative team.

#LI-Remote

Minimum Education Requirements:

High school degree or equivalent required unless otherwise noted above

Location

Hingham

Time Type

Full time

Salary Range: $98,190.00 - $120,010.00

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting.  We may ultimately pay more or less than the posted range, and the range may be modified in the future.  An employee’s pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note:  No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

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