Job Description
Develops medical policies for coverage guidance of new technology, medical/dental procedures and review clinical codes. (CPT/HCPCS). Initiates the process for internal and external review of corporate medical/dental and administrative policies to meet all regulatory and accrediting agencies. Responds to internal and external inquiries regarding policies, benefit application and reimbursement strategies. Represents the Healthcare Division as clinical and/or coding advisors. Analyzes clinical service codes that are applicable to medical policy, including but not limited to: research of newly developed codes, review of claims data, and assessment of system configuration.
What You’ll Do
Initiate and coordinate internal and external reviews of medical and dental policies in accordance with regulatory requirements and organizational standards.
Identify opportunities to develop, modify, or update medical and dental policies based on business needs, regulatory changes, emerging technologies, and clinical evidence.
Conduct comprehensive policy and technology assessments using scientific literature, regulatory guidance, clinical practice guidelines, professional position statements, and applicable industry resources. Analyze findings, develop recommendations, and draft policies.
Maintain internal and external medical policy websites and online policy manuals to ensure information is current, accurate, and accessible.
Draft and coordinate provider and member communications regarding new medical or dental policies and significant changes to coverage guidelines.
Serve as a subject matter expert on medical policy, coding, coverage, reimbursement, and integrated benefit design for internal and external stakeholders.
Analyze claims data, utilization patterns, reimbursement trends, and prior authorization activity to evaluate policy performance and develop data-driven recommendations for policy and process improvements.
Collaborate on medical policy development and implementation projects from initiation through completion, ensuring alignment with applicable federal, state, regulatory, and organizational requirements.
Perform after-hours system updates to promote policy-related application changes from pre-production to production environments while minimizing operational disruption.
Conduct comprehensive post-configuration testing of medical policy authorization workflows and business logic to validate functionality, ensure alignment with established requirements, and provide final business sign-off.
Lead advisory group meetings with specialty providers to review emerging clinical research, scientific literature, and other evidence to determine potential medical policy updates.
Participate in Blue Cross and Blue Shield Association medical policy meetings to evaluate association-level guidance and determine implications for internal policies.
Collaborate with vendors and internal and external stakeholders to interpret, communicate, and maintain current laboratory policies.
Research newly released CMS and AMA codes to evaluate coverage implications and determine appropriate policy and reimbursement requirements.
Support departmental and enterprise initiatives through research, analysis, documentation, and cross-functional coordination to advance medical policy objectives.
Provide medical policy expertise in support of enterprise initiatives focused on reducing operational costs, improving consistency, and increasing transparency in coverage decision-making.
What You Bring
Registered Nurse or Licensed Practical Nurse
3+ years of experience in related field
AAPC Certified Professional Coder (or obtain coding licensure withing first year)
What You’ll Get
The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community
Work-life balance, flexibility, and the autonomy to do great work
Medical, dental, and vision coverage along with numerous health and wellness programs
Parental…