Responsible for research, analysis, evaluation, development and maintenance of BCBSM/BCN medical policies in collaboration with medical directors and corporate committees. This includes oversight and coordination of all activities related to the development and maintenance of medical policies in accordance with current peer-reviewed literature, certificates, riders, federal and state mandates, CMS guidelines, BCBSM/BCN policies and procedures. Responsibilities include investigation of new procedures, technologies, devices, healthcare services and maintenance of clinical documentation, treatment modalities as well as communication and education to internal and external stakeholders including team members, leadership and other areas throughout the corporation * Identify and evaluate new treatment and technology for potential coverage by BCBSM/BCN. Develop policies for presentation to various committees, including Joint Uniform Medical Policy (JUMP) and Medical Affairs Policy Review Committee (MAPRC). Develop and maintain a resource base (FDA, BCBSA, CMS, Hayes, etc.) for additional technology and current literature review to support medical policy decisions. * Research, analyze and compile supporting documentation of evidence-based literature sourced from national medical professional organizations, peer-reviewed medical literature, specialty associations, society publications and guidelines for medical policy determinations for new policy development and annual review of active medical policies. * Coordinate all aspects of policy development and maintenance of assigned medical policies in collaboration with internal team and assigned medical policy directors. The medical policy coordinator is expected to be a medical policy subject matter expert that can advise and partner with the team throughout the medical policy process. * Provide clinical knowledge and medical policy expertise for medical policy development and maintenance, inquiries, projects, initiatives, and work groups as related to medical policy interpretation and coding (ICD-10, CPT, HCPCS) of services identified on policies. * Respond to moderate and complex medical policy inquiries to ensure appropriate medical policy interpretation and utilization of policy criteria. * Active participation in consultations with internal teams and external practitioners, providers, medical groups and professional associations, as necessary, to obtain advice and expertise in development and maintenance of medical policies. * Other duties as assigned by leadership. Department Preferences: * Excellent research skills which include the ability to analyze peer-reviewed medical literature for statistical significance. * Excellent written communication skills including grammar, spelling, punctuation and standardized formatting to produce professional medical policies published for both internal and external stakeholders. * Excellent oral communication skills with the ability to present assigned medical policies including supporting rationale to large committees. "Qualifications" * 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. * Registered Nurse with current unrestricted Michigan Registered Nurse license required. * 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 CMS benefit guidelines preferred. * Knowledge of BCBSM medical management policies, procedures and processes, claims processing flow, and utilization management policies and procedures preferred. * Knowledge of BCBSM/BCN reimbursement policies preferred. * Knowledge of NCQA, CMS, 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.
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