Medical Policy & Coding Project Consultant- RN/CRNP

Mpc Project Consultant

Base pay is influenced by several factors including a candidate's qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it's why our employees consistently vote us one of the "Best Places to Work in PA."

The MPC Project Consultant is responsible for leading and supporting cross-functional initiatives related to Medical Policy and Coding (MPC). This role applies advanced knowledge of clinical care, evidence-based practice, coding, claims administration, healthcare data analysis, IT&D, and operational workflows to support the development, evaluation, and implementation of organizational initiatives. The consultant supports Capital's mission by researching and developing clinical services that align with evidence-based practice and benefit coverage requirements. The role serves as a clinical, business, and technical resource to MPC Clinical and Coding Coordinators and collaborates with stakeholders across the organization to drive effective decision-making and process improvements.

Responsibilities and Qualifications

• Thoroughly research, maintain, and identify CPT, CDT, HCPCS, ICD-10 and revenue codes to meet business needs.
• Independently manage episodic/special projects, including (and not limited to): In-depth clinical and business research, collaboration with other departments, and development of sound, evidenced-based policy/clinical recommendations both internally and externally. Independently draft and/or revise medical policies classified as Large or X-Large (often complex) related to projects and other policies, as assigned.
• Independently prepares recommendations for internal audits, client audits and/or insurance department audits, for MPC leadership and the Capital Legal Team.
• Attends external BCBSA MPP Monthly meetings, conducts in-depth clinical research for scientific evidence, and proposes medical policy adoption to MPC Leadership.
• Conducts independent interdepartmental networking in support of clinical initiatives involving medical policy and coding activity.
• Independently completes new code Phase II clinical review of quarterly and annual codes. Assists with clinical review of annual ICD-10 code adoption/review.
• Work collaboratively with the Coding Team Lead to provide training to staff.
• Perform other related duties as assigned.

Skills:

• Ability to interact with a high level of professionalism with all levels of internal/external personnel, including preparing written materials and oral presentations for clinical, technical and non-technical audiences. Includes seasoned skills to lead meetings and ensure mutually agreeable solutions among multiple departments, as well as, successful completion of a project.
• Demonstrated analytical skills.
• Able to gain knowledge of new clinical and business processes and issues quickly.
• Advanced problem-solving and structured analysis/design techniques. Including the ability to understand complex interrelated systems and independently resolve business and technical problems encountered.
• Ability to adapt to constantly changing priorities. Includes ability to work independently with minimal supervision to inspire teamwork among diverse groups.
• Project management ability and use of project plans. Ability to handle information in a confidential manner by adhering to HIPAA and Compliance expectations.
• Ability to communicate effectively professionally, respectfully in written and verbal form with both internal and external customers.
• Ability to work independently, schedule and manage time effectively.
• Ability to adjust to changing job requirements and priorities in order to meet dynamic needs and workflow.

Knowledge:

• Knowledge of the health care industry, including standards, policies, familiarity with clinical and business practices, and procedures for multiple departments/systems, especially those related to claims administration, information services, provider networks, clinical, and SIU. Also includes an understanding of the corresponding business practices and interrelationships with other Plans.
• Knowledge of technological applications, terminology and concepts. Includes knowledge of web-based technologies (Internet/Intranet), SharePoint, SAS, Microsoft Access, Microsoft Excel, reporting and testing software, as well as other Microsoft Office Suite tools.
• Strong working knowledge of benefits, payment policies and claims operating systems.
• Strong working knowledge of the principles of both professional and facility payment processes, benefits and claims adjudication processes.
• Strong working knowledge of Government regulatory and accrediting requirements (PPACA, FEP, MS, Pennsylvania state regulations, NCQA, URAC, OH and Medical Assistance.
• Advanced understanding of medical terminology.
• Basic knowledge of current and emerging treatment modalities with the ability to analyze and interpret medical policy and benefit coverage interrelationships.
• Knowledge of IT&D, pre-configuration and configuration and various steps to compose and circulate a medical policy to completion, as needed.
• Proficiency in analyzing data and presenting data in an effective manner in order to meet business needs.
• Proficiency in data analysis/trending through analyzing claims data related to medical coding.

Experience:

• Minimum of 5 years in a clinical setting, and medical coding position, preferably in a managed care/health insurance related position.
• Preferred five (5) years' experience of medical coding including: ICD-10, CPT, CDT, HCPCS and revenue codes.

Education and Certifications:

• Current, non-restricted clinical license.
• Bachelor's Degree in Nursing, required.
• Advanced Practice Provider degree, preferred.
• The position requires a certification from the American Association of Professional Coders (AAPC) Medical Coding. If the employee does not have the AAPC certification, the course will be offered with timing at management's discretion. Continuing education credits must be satisfied to maintain the certification. If the AAPC certification is not obtained/maintained successfully, it could result in termination.

Work Environment:

• Work at home, office

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must occasionally lift and/or move up to 5 pounds.

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you'll help us live our mission of improving the health and well-being of our members and the communities in which they live.