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    Medical Policy Analyst - Baltimore, MD, United States - Blue Cross and Blue Shield Association

    Blue Cross and Blue Shield Association
    Blue Cross and Blue Shield Association Baltimore, MD, United States

    2 days ago

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    Description
    Medical Policy Analyst - RN (Remote)

    In collaboration with the Medical Director, the Medical Policy Analyst will research, analyze, evaluate, and revise medical policies and operating procedures to support the corporate philosophy, provider and member contracts, and accepted standard of medical practice.

    We are looking for an experienced professional to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities.

    Performs in-depth research on medical topics identified in existing medical policies and operating procedures scheduled for revision or updates based upon changes in the standard of care.

    Evaluates current peer-reviewed articles and other literature to determine its appropriateness of clinical guidance and mandated legislation in support of and inclusion in policies.


    • In collaboration with the Medical Director, revise evidenced-based medical policies and operating procedures in compliance with legislative mandates, contractual provisions, corporate philosophy, and accepted standards of medical practice in order for them to be applied uniformly and consistently across all lines of business.
    • Maintains the Medical Policy Reference Manual (MPRM) including resource files and publications. Ensures dissemination of medical policies and operating procedures to internal and external customers according to CareFirst application protocol and regulatory standards.

    Education Level:

    Bachelor's Degree in Nursing, Public Health, English or related field directly related to the position OR in lieu of a bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

    3 years Clinical experience within the field of Medical Surgical, Mental Health, Durable Medical Equipment, and/or Utilization Management, including some experience in research methodology and systematic evaluation of medical literature and translation of evidence into policy in a healthcare setting.

    Ability to analyze essential facts, make timely and sound decisions, resolve performance and job-related issues. Working knowledge of medical insurance and managed care principles and knowledgeable of CPT and ICD-10 coding systems. Knowledge of all types of medical necessity decisions including various places of service and provider types.

    • Knowledge of principles, practices, evidence-based guidelines and standardized processes and procedures for evaluating medical support operations business practices.
    • This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. Medical Policy

    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.

    Please visit our website to apply:

    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.

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