Med Policy Developer/Research Specialist II

APOLIS2024

Medical Policy Developer/Research Specialist II
Phoenix, AZ (Remote, Preferred AZ candidate)
6 months CTH
Pay range - $35-37/Hour on W2

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.

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 Client 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

ALL LEVELS
• Each progressive level includes the ability to perform the essential functions of any lower levels.
• The position 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.
Remote/Hybrid/On-site: hybrid, onsite weekly on Wednesdays

COMPETENCIES
REQUIRED COMPETENCIES
1. Required Job Skills
• Intermediate PC proficiency
• Intermediate Adobe PDF Standard proficiency
• Intermediate word processing, spreadsheet and presentation software proficiency (Applies to All Levels)
2. Required Professional Competencies
• Maintain confidentiality and privacy
• Advanced clinical knowledge
• Practice interpersonal and active listening skills to achieve customer satisfaction
• Compose a variety of business correspondence
• Follow and accept instruction and direction
• Establish and maintain working relationships in a collaborative team environment
• Organizational skills with the ability to prioritize tasks and work with multiple priorities
• Independent and sound judgment with good problem solving skills (Applies to All Levels)
3. Required Leadership Experience and Competencies
• N/A
PREFERRED COMPETENCIES
1. Preferred Job Skills
• Advanced PC proficiency
• Advanced Adobe PDF Standard proficiency
• Advanced processing, spreadsheet and presentation software proficiency (Applies to All Levels)
2. Preferred Professional Competencies