Resp & Qualifications
PURPOSE: Reporting to the Sr. Director of Medical Review, Appeals, and Healthcare Policy, the Manager, Healthcare & Reimbursement Policy is responsible for research, development, maintenance, and implementation of evidence-based, clinically sound, jurisdictionally compliant corporate medical and claims adjudication policies and technology assessments. In addition to providing support on clinical policy, this position is responsible for ensuring CareFirst clinical programs are meeting all legislative and regulatory requirements, providing support and expertise in medical benefit design, handling escalated issues of a clinical or policy nature that come from the Strategic Business Units and supporting Executive Management’s perspective on key technologies. In brief, the function of this role is to ensure that CareFirst is on the cutting edge of medical and payment policy to accelerate the emergence of a value-based health care system.
The incumbent supports the ongoing thorough research, documentation of research, and promulgation of new and existing policies to appropriate internal and external customers while managing the collaborative evaluation, revision and maintenance of on-line claims adjudication. He or she functions as the in-house expert for medical and payment policy, pricing, and coding.
In addition, the incumbent represents the Medical Affairs Division on matters of health policy in order to influence subscriber quality medical care and positive relations with providers and the community. The role requires collaboration with and support of several key stakeholders across the organization as well as externally including:
Multiple business areas within the CareFirst Medical Affairs division (Medical Review, Clinical Appeals, Provider Relations, Care Management, Information Technology, Compliance, and others);
Strategic Business Units, Sales and Marketing, Communications, Legal, Government Mandates; and
other Core Business Partners.
PRINCIPAL ACCOUNTABILITIES: Under the general direction of the Sr. Director of Medical Review, Appeals, and Healthcare Policy the Manager , Healthcare & Reimbursement Policy’s responsibilities and accountabilities include, but are not limited to, providing direction, leadership, and oversight for the following functions:
Corporate Medical Policy Administration and Medical Technology Assessment: Responsible for managing the research, development, maintenance and implementation of corporate medical and claims adjudication policies. Collaborates with Medical Directors, Federal, State and Local entities, internally and externally to notify and interpret healthcare policy for new or revised benefit structures.
Accountable for managing up to date assessment of both FDA approved and emerging new medical treatment technologies and protocols.
- Ensures that accurate and timely information is provided based on in-depth review of the issue, current sources, and corporate philosophy and standards
- Manages the informed review of current benefit contracts and recommendations for new or revised benefit structures
- Manages the authoring of articles and providing educational programs as requested related to healthcare policy
- Responsible for timely notification and explanation of key policy changes to appropriate internal and external customers
Systems Oversight: Accountable for managing corporate systems processes and strategies that involve translation of medical policy into claims adjudication which impacts over $ 200 million dollars in care cost. Manage Claims software, reviews and customize as necessary, and simultaneously on appropriate platforms in collaboration with other departments. Includes knowledge of ICD-10 and understanding of Claims editing tools
- Ensures consistent claims adjudication on all platforms utilizing the appropriate software product
- Ensures that new versions/releases of software are thoroughly reviewed, customized as necessary, and implemented simultaneously on appropriate platforms in collaboration with other departments
- Accountable for compliance with current medical policies and benefit structures
- Ensures that policies/edits that are contractually and jurisdictionally compliant and that system components/files that are accurately and timely maintained
Reimbursement Policy- Responsible for managing the research, development, maintenance and implementation of corporate reimbursement policies resulting in consistent claims payment across all platforms, improved provider satisfaction, a reduction in administrative appeals, reduction in interest payments, and a reduction in regulatory complaints.
Clinical Consultation: Collaboration with all internal departments (i.e. Medical Review, Clinical Appeals, Legal, Provider Relations, Corporate Communications, Information Technology, Government Affairs, and Care Management) and external customers (including physicians, non-physician providers, facilities, vendors) regarding coding practices, policy interpretation and new/existing technology.
Healthcare Policy Representation: Responsible for representing Medical Affairs Division on matters of healthcare policy in order to influence subscribers, providers and community.
- Manages the exploration of opportunities and recommending and effecting change for future initiatives or partnerships to improve relationships with internal and external customers.
Team Leadership and Administrative Oversight: Manages the day-to-day activities of the Healthcare Policy, Technology Assessment and Reimbursement Policy Department, including managing, coaching, and guiding associates in order to implement departmental, divisional, and organizational mission/goals. Develops annual goals, and prepares, monitors, and analyzes variances of departmental budgets in order to control and appropriately allocate resources.
- Healthcare Policy expert with a minimum of 5 years’ experience in a health insurance environment, with focus on policy development and implementation in a healthcare setting.
- At least 5 years of prior experience directly managing staff and overseeing fiscal resources.
- Professional coding certification by a national organization (i.e., AAPC or AHIMA).
- In-depth knowledge and understanding of operational, legal/ethical, and system compliance requirements related to healthcare policy development and implementation.
- In-depth knowledge of standards and laws and regulations related to the health care environment.
- In-depth knowledge of medical and claims policy development;
- In- depth knowledge of reimbursement policy; experience with developing and implementing corporate reimbursement policies to ensure consistent and accurate claims payment
- Claims operations/medical review experience in a health insurance setting.
- Clinical Quality and Process Improvement
- Evidenced-based Research, Evaluation and Interpretation
- Budget and Fiscal Management
- Written and Oral Communication/Presentation Skills
- Project Management
- Relationship Management
- Influencing and Negotiating
- Decision Making
- Proficiency in Microsoft Office Suite
- Navigation of mainframe computer systems, including database software packages
- Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
RN with Bachelors or Master’s degree in nursing, or other health-related discipline or MBA. Evidence of experience with Medicare Advantage or Medicaid.
Health Care Policy
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Please apply before: 11/24/2019
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The physical demands described here are representative of those that must be met by an associate to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
This associate is primarily seated while performing the required duties. Occasional walking and standing are required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Must be able to manage operations at multiple sites at various locations. Weights of up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship