Responsible for oversight and coordination of all activity related to development and maintenance of medical policy and benefit interpretation in accordance with BCN certificates, riders, waivers, statewide policies, CMS and HCFA guidelines, BCBSM policies and procedures. Responsibilities include investigation of new procedures, technologies, drugs, devices, maintenance of clinical documentation, treatment modalities as well as communication and education to team members.
ESSENTIAL DUTIES AND RESPONSIBILITIESinclude the following. Other duties may be assigned.
Identify and evaluate new treatment and technology documentation for potential coverage by BCN/BCBSM. Develop policies for presentation to various committees, including Statewide Benefit, Joint Uniform Medical Policy or BCN Medical Management. Develop and maintain a resource base (FDA, TEC, DATTA, BCBSA, etc.) for additional technology assessments and application to medical policy resources.
Research and compile supporting documentation to medical policy determinations and benefit interpretations. Maintain documentation for internal and external communications. Initiate internet and medical literature searches for Medical Policy, Care Management, Quality Improvement and Pharmacy Management.
Provide knowledge and expertise for projects, initiatives, and work groups.
Respond to moderate and complex inquiries from PCGs/PCPs, team members or other departments to ensure appropriate benefit interpretation. Coordinate benefit issues with the committee chairperson to assure issues are added to the Statewide Benefits Committee meeting agenda – facilitating uniform benefit interpretation.
Review and coordinate claims to ensure prompt and accurate claims processing; specifically, multi-line surgery, benefit-related and claims requiring review of medical records.
Maintain the Professional Benefits Claims Manuals ensuring the most current information on claims payments, processing guidelines and benefits are available and used for reviews and determinations.
Collect and coordinate the distribution and/or provision of information to be reviewed by the BCN Benefits Committee and Medical Director(s) for medical policy determination and benefit interpretation statements. Develop and maintain a network of contract people within BCN/BCBSM and BCBSA and external vendors.
Coordinate the distribution of BCN draft policies, assimilate local BCN Benefit Committee’s responses and prepare return of drafts to BCN Benefit Committee. Attendance at BCN Benefits Committee meetings is required. Coordinate with BCBSM Medical Policy department to ensure consistency of policy development and benefit interpretation. Prepare and present special cases to the BCN/BCBSM Medical Director.
Coordinate the development and maintenance of medical policy manuals and resources.
Other duties as assigned by leadership
EDUCATION AND/OR EXPERIENCE
Bachelor's degree required; major in nursing or other health care related field preferred.
Four (4) years broad clinical experience required.
Three (3) years utilization/quality management experience required, managed care environment preferred.
Two (2) years medical policy or benefit determinations experience preferred.
Two (2) years coding or medical billing experience preferred.
CERTIFICATES, LICENSES, REGISTRATIONS
1. Registered Nurse with current unrestricted Michigan Registered Nurse license required.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
OTHER SKILLS AND ABILITIES
Self-motivated, ability to work independently and as part of a team, ability to motivate team
Excellent verbal and written communication skills required.
Excellent organizational skills, multi-tasking and timelines with planning and development required.
Excellent interpersonal skills. Ability to interact internally and externally at all levels of the organization required.
Demonstrated problem solving and decision-making skills.
Demonstrated research and analytical skills
Demonstrated understanding of primary code classifications, ICD-10, CPT and HCPCS, preferred.
Knowledge of Facets and system configuration required.
Knowledge of policies and procedures, member certificates (riders, waivers, exclusions and limitations) preferred.
Knowledge of HCFA benefit guidelines preferred.
Knowledge of BCBSM medical management policies, procedures and processes, claims processing flow, and utilization management policies and procedures preferred.
Knowledge of BCN reimbursement policies preferred.
Knowledge of NCQA, HCFA, State and Federal HMO regulations preferred.
Knowledge of current medical and clinical practices, including community standards of practice.
PC literate in commonly utilized software programs.
All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.