RN Medical Policy Specialist

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Job Description:

The Medical Policy Specialist reports to the leader of Medical Policy Administration and is responsible for researching, maintaining, and continuously improving medical policy documents. 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 clinical research skills, coding skills, critical thinking skills and excellent documentation skills.

This position is eligible for the eWorker persona.

Key Responsibilities:

• Responsible for researching clinical content (papers, PubMed, etc), document findings and provide recommendations on research outcome
• Responsible for conducting comparative market analysis for coverage positions, analyzing utilization, volume, and data trends.
• Responsible for conducting clinical outreach for clinical trial research and study outcomes, ongoing assessments of literature and keeping abreast of state and federal mandates.
• Responsible for documenting meeting minutes of various meetings, including but not limited to, the Medical Policy Group meeting, the Association Medical Policy Group meeting and others as needed.
• Responsible for creating the agenda for the Medical Policy Group meeting for distribution to the Massachusetts Medical Society and interested providers.  In preparation for the meeting, provide comparative market analysis and literature reviews for Medical Director.
• Represent Medical Policy Administration in various divisional and interdepartmental meetings.
• Responsible for providing analysis and responses of 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.
• Responsible for reviewing overturns by conducting clinical research and providing MPA team with findings.
• Responsible for updating medical policies as needed.
• Serve as a business consultant for other departments regarding coding concepts and guidelines.
• Review yearly code set additions/deletions for impacts to medical policies and provide coverage recommendations.
• Responsible for reviewing and enforcing Carelon policies by identifying any code changes that impact the Carelon program and BCBSMA.  This includes Radiology, Genetic Testing, Sleep Testing and Radiation Oncology.  Act as a liaison to operational areas within BCBSMA.
• Responsible for reviewing Local Coverage Determinations (LCD) for Medicare Advantage and identifying any code changes that impact edits.  Implement edit changes as necessary.
• Other duties as assigned.

Qualifications:

• RN or PA-C required
• CPC required
• BSN preferred
• Proficient in medical writing
• Specialty preferred in women’s health including IVF and NICU services as well as experience with gender affirming services
• 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

Minimum Education Requirements:

High school degree or equivalent required unless otherwise noted above

Location

Hingham

Time Type

Full time

Salary Range: $89,820.00 - $109,780.00

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 la