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    • Medical Policy Clinical Specialist - Mountlake Terrace - Premera Blue Cross

    Premera Blue Cross
    Premera Blue Cross Mountlake Terrace

    4 weeks ago

    Default job background
    Full time
    Description
    Workforce Classification:Telecommuter

    Meaningful Work and Improving People's Lives

    Premera strives to improve customers' lives by making healthcare work better. Our employees drive real change by transforming healthcare through our culture of employee growth, collaborative innovation, and inspired leadership.

    We create an environment where employees can excel and top talent is attracted, retained, and thrives. As a testament to these efforts, Premera has been recognized on the America's Dream Employers list.

    We support our members, customers, and communities through our Healthsource blog: healthsource.premera.com.

    Job Summary

    The Medical Policy (MP) Clinical Specialist develops and maintains medical policies to guide coverage determinations for new and developing technology, pharmacologic agents or health care services where concerns regarding safety, efficacy or wide variance in utilization exist.

    Key Responsibilities

    • Drive individual medical policy development and revision to ensure that company policies reflect the most current published scientific literature and are usable for clinical staff.
    • Monitor the external environment regarding new and evolving medical technology by following on-line updates from Hayes, Agency for Healthcare Research & Quality (AHRQ), National Institute of Health (NIH), Washington State Health Care Authority (WA-HTCA), Oregon Health Evidence Review Commission (OR-HERC), Center for Medicare and Medicaid Services (CMS) and other sources.
    • Interpret statistical analyses of clinical studies and published statements from professional societies. Translate that information into summary statements for inclusion in policy documents.
    • Liaise with Clinical Appeals Department to regularly review data from same specialty and independent review organizations. Utilize the data to inform the need to revise medical policy and coverage criteria.
    • Analyze qualitative and quantitative data to measure the impact of medical policy and utilization activities to determine the business and member value of medical policies. Conduct internal research to assist business decisions regarding archival of policies.
    • Present medical policy summaries for discussion and clinical vetting at the Medical Policy Committee, the Pharmacy and Therapeutics Committee, or other committees as requested.
    • Develop and present clinical education materials for review staff (doctors and nurses) to support appropriate use and interpretation of policies and clinical review criteria sets.
    • Use clinical knowledge and expertise, and internal research when needed, to respond to external and internal inquiries.
    • Act as a clinical liaison representing Medical Policy to cross departmental committees and work groups working on benefits, legislative mandates, preventive care and other issues.
    • Serve as Premera liaison with Blue Cross Blue Shield Association Office of Clinical Affairs and represent the Premera on implementation and topic selection calls.
    • Other duties as assigned.

    Requirements

    • Bachelor's degree in health services or clinical science (such as Nursing, Pharmacy, Public Health, Epidemiology, Biostatistics, Genetics, Health Technology).
    • Registered Nurse, Physician's Assistant, or Nurse Practitioner with five (5) years' clinical experience.
    • Four (4) years of health plan experience in utilization management to include any of the following: pre-service review, post services review, and/or clinical appeals.
    • Master's degree in health care or business-related field. (Highly Preferred)
    • Management or project management experience. (Preferred)
    • Health plan experience in developing medical policies or criteria sets. (Preferred)
    • Familiarity with ICD-10 and CPT coding. (Preferred)
    • Familiarity with claim payment processes. (Preferred)
    • Superior clinical writing skills.
    • Excellent analytical, research and critical thinking skills. Ability to evaluate scientific studies across the spectrum of medical specialties.
    • Excellent oral and written communication skills with ability to communicate well across all levels of the company.
    • Proficient in a Windows environment utilizing Outlook, Word, Excel, PowerPoint, and SharePoint.
    • Proven ability to drive projects to completion and effectively facilitate work groups.
    • Proven ability to work both independently and as a member of a team to prioritize work.
    • Able to manage multiple complex projects and priorities.

    Compensation

    The salary range for this role varies based on factors including geographic location, market conditions, and specific skills and experience. The national salary range is $87,000 - $147,900. The national plus salary range is used in higher cost of labor markets including Western Washington and Alaska and ranges from $99,100 - $168,500.

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Mountlake Terrace