RN Medical Policy Development/Research Specialist

PURPOSE OF THE JOB

• Perform medical technology research to support the Medical Director Staff and Medical Policy Panel with decisions to ensure that medical policies are consistent with the standards of accepted medical practice in the community.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

• 2 year(s) of experience in clinical field of practice, health insurance, or other health care related field (All Levels)
• 1 year(s) of experience in medical policy and technology research field (Applies to Level 2)

• 2 year(s) of experience in medical policy and technology research field (Applies to Level 3)

 Required Education

• Associate’s Degree in general field of study or Post High School Nursing Diploma or Certification (LPN only) from an approved program (Applies to All Levels)

Required Licenses

• Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN, LPN, LPT, LBSW, LMSW, or LCSW. (Applies to All Levels)

Required Certifications

• N/A

PREFERRED QUALIFICATIONS

• 3 year(s) of experience in clinical field of practice, health insurance, or other health care related field (All Levels)
• 1 year(s) of experience in claims retrospective review, utilization management, case management, appeals and grievances or quality review field (Applies to All Levels)

• Bachelor's Degree in Nursing or related field of study (Applies to All Levels)

• Active, current, and unrestricted State of Arizona (a state in the United States) license to practice as a Registered Nurse (Applies to All Levels)

• N/A

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

Level 1

• Perform medical technology research related to coverage guidelines and new technology and provide evaluation and summarization to Medical Director Staff and/or Medical Policy Panel
• Perform medical technology research as requested by other areas of BCBSAZ thru the Medical Policy Referral Form
• Develop and revise coverage guidelines and criteria as requested by management, Medical Director staff or Medical Policy Panel
• Communicate medical policy information in protocol format to all areas of BCBSAZ requiring this information
• Participate as a contributing member on the Medical Policy Panel providing medical policy issues for discussion and, as required, on the Clinical Coding Governance Committee (CCGC).
• Maintain a thorough knowledge of all BCBSAZ medical coverage guidelines and other policies, such as BCBS Association Medical Policy Reference Manual, MCG care guidelines and/or Change Healthcare InterQual, and eviCore criteria.
• From the direction of management, Medical Director staff or Medical Policy Panel, facilitate external consultant reviews concerning a coverage guideline or new technology. Responsible for initiating the consultation and providing a summarization concerning the external review to the requestor. Responsible for arrangements for appropriate reimbursement for the consultant’s review.
• Communicate medical policy information in protocol format to healthcare providers upon request
• With moderate assistance and review by management, perform basic level of code review
• Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations
• Maintain all standards in consideration of State, Federal, BCBSAZ and other accreditation requirements
   

Level 2

• Working independently, recognizes necessity of an external consultant review concerning a coverage guideline or new technology, summarizing and reporting this information to management to facilitate the process as outlined for Level II
• With review by management, independently perform intermediate code review with knowledge and understanding of coverage guideline development/revisions with recommendations to the Clinical Coding Governance Committee (CCGC) for integration into benefit programming
• Responsible for the training, development and support of grade level I staff under an established training program
   

Level 3

• With review by management, independently perform advanced code review with advanced knowledge and understanding of coverage guideline development/revisions with recommendations to the Clinical Coding Governance Committee (CCGC) for integration into benefit programming.
• Working independently, initiate research from resource materials, e.g., clinical journals, periodicals, CMS (Medicare) guidelines and publications, BCBSA publications, other BCBS plans, and internet resources relating to technical, clinical and coverage guidelines, summarizing and reporting this information to management for further action
• Responsible for the training, development and support of grade level I and II staff under an established training program

LEVEL 4

• Assist manager with the implementation of daily operations with regard to guideline development and revisions, staff supervision, as well as necessary coaching to help each staff member reach personal, professional and department goals
• Assist manager with the coordination of all aspects of the Medical Policy Panel and Medical Director Meeting, including preparation, agenda and minutes.
• Assist manager with the completion of the monthly, quarterly and annual reporting to Director
• Assist manager with the coordination of all aspects of the annual review(s) of MCG, eviCore and/or Change Healthcare InterQual criteria updates
• Assist manager with providing oversight to responsible staff for the monthly review of BCBS Association Medical Policy and Reference Manual (MPRM) updates
• Assist manager with providing the initial training and instruction for both professional and technical staff and designating the oversight of staff regarding training of new staff at the desk level of instruction/training
• Responsible for the training, development and support of grade level III staff under an established training program
• Conduct, and/or participate in internal committees that further the goals of BCBSAZ, the Health Services Division and the Medical Policy & Technology Department
• Working independently, perform advanced code review with advanced knowledge and understanding of coverage guideline development/revisions with recommendations to the Clinical Coding Governance Committee (CCGC) for integration into benefit programming

ALL LEVELS

• Each progressive level includes the ability to perform the essential functions of any lower levels.
• The position has an onsite expectation of 0 days per week and requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements
• Perform all other duties as assigned.