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    Senior 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

    6 days ago

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    Description
    Senior Medical Policy Analyst - RN (Remote)

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

    The Senior Medical Policy Analyst will work closely with organizational teams to ensure medical policy and operating procedures are accurately operationalized for optimal claims adjudication and utilization management.

    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.

    Consistently maintains an awareness of trends and current literature related to health and policy issues in the public and professional domains.

    In collaboration with the Medical Director, performs in-depth research on topics identified for the development of potential medical policies.

    Critically research clinical evidence-based research resources, as well as analyze quantitative and qualitative claims utilization data within the scope of research to determine its appropriateness for support of and inclusion of criteria in existing medical policies and operating procedures.


    • Writes evidenced-based medical policies and operating procedures to support compliance with legislative mandates, new technology assessments, contractual provisions, corporate philosophy, and accepted standards of medical practice in order to be applied uniformly and consistently by across all lines of business, as deemed appropriate by the Medical Director.
    • Lead the discussion during the Medical Policy Committee meetings by articulating the clinical scope and conveying the clinical guidance associated with the revision and development of medical policies and operating procedures. Collaborate with organizational operations teams to assist with operationalizing the medical policy and operating procedures based on the clinical and legislative guidance outlined through clinical editing and benefit configuration.
    • 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.
    Experience: 5 years Clinical experience within the field of Medical Surgical, Mental Health, Durable Medical Equipment, and/or Utilization Management, including significant experience in research methodology and systematic evaluation of medical literature and translation of evidence into policy in a healthcare setting
    Masters degree in nursing or related health care discipline.

    • Experience with a health care payer organization with a working knowledge of scientific terminology as well as strong medical and research concepts experience to include dissemination of policy-related materials such as policy issue briefs, comment letters, and advocacy documents.
    Ability to analyze essential facts, make timely and sound decisions, make recommendations and resolve performance and job-related issues.

    Knowledge of NCQA requirements of utilization review, Case Management standards and guidelines, appeal rights and responsibilities, and Regulatory requirements at the state and federal level for health care administration and Carrier standards.


    • 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.
    • Advanced knowledge in the use of web-based technology and Microsoft Office applications such as Word, Excel, and Power Point Advanced. Proficient with database entry and query software.
    • 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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