Remote- Med Policy Developer/Research Specialist II

Remote Medical Policy Developer/Research Specialist Nurse

Schedule: Monday-Friday (8am-5pm)

Contract: 6 month contract to hire

Pay Rate: $35-39/hour

Specific Duties:

• 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 through the Medical Policy Referral Form
• Develop and revise coverage guidelines and criteria as requested by management, Medical Director staff or Medical Policy Panel
• 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 company 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

Must Have Qualifications/Experience:

• Nursing License (LPN, RN, APRN)
• Utilization Review experience
• Experience working for a health plan
• Must enjoy writing and extensive research
• Experience with policy development is a plus

Pride-Health offers eligible employee's comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, auto, home insurance, pet insurance and employee discounts with preferred vendors. Equal Employment Opportunity

Pride-Health is an equal opportunity employer. We do not discriminate on the basis of race, religious creed, color, national origin, ancestry, physical disability, mental disability, reproductive health decision making, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, veteran or military status, or any other characteristic protected by applicable federal, state, or local law.

Fair Chance Employment

Pride-Health is a Fair Chance employer. We consider all qualified applicants, including those with criminal histories, in a manner consistent with applicable state and local Fair Chance laws and ordinances, including, the California Fair Chance Act and all applicable local Fair Chance ordinances.

Accommodations

We are committed to providing reasonable accommodations to applicants and employees with disabilities. If you require a reasonable accommodation to participate in the application or interview process, or to perform the essential functions of this role, please contact us.

Only applicable for San Francisco Candidates:

Under the San Francisco Lactation in the Workplace Ordinance, we will provide written notice of lactation accommodation rights, and this notice will automatically be given upon hiring, any inquiry of parental leave or lactation accommodation.

Only applicable for Kentucky positions: For this type of employment, state law requires a criminal record check as a condition of employment. This applies to direct care staff (Examples: RN, LPN, Nurse Aides, Therapists) referred to Kentucky nursing facilities, assisted living communities, or long-term care facilities, in accordance with KRS 216.793.