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Job Description:

Summary:

The Medical Policy Coordinator is responsible for research, analysis, evaluation, and the development and maintenance of medical policies following the corporate medical policy development process in conjunction with Medical Policy leadership and applicable Medical Director(s).

Essential Accountabilities:

+ Develops and maintains corporate medical policies as recommended by the Corporate Medical Policy Committee.

+ In collaboration with the Lead Medical Policy Coordinators, tracks the annual review requirements of assigned policies ensuring all annual reviews are completed in compliance with National Committee on Quality Assurance (NCQA) timeframes and in accordance with departmental protocols. DLP’s.

+ Responsible for design and oversight for overall policy criteria in collaboration with Medical Directors and Lead Medical Policy Coordinators.

+ Analyses evidenced based scientific literature sourced from national medical professional organizations, peer-reviewed medical literature, provider specialty associations, society publications and guidelines for both new policy development and for the annual review of assigned policies.

+ Conducts research on best practice for individual medical policy positions.

+ Conducts comparative analysis of Blue Cross Blue Shield Association (BCBSA) Reference Policies, competitor positions and community related trends and compiles recommendations for both new policy development and for the annual review of assigned policies with medical directors and the Corporate Medical Policy Committee (CMPC).

+ In collaboration with Code Classification, MD’s and CMP Leads works to identify requirements for data analysis of assigned medical policies assessing the utilization and cost effectiveness for their assigned policy. This data along with clinical and analytical expertise is used to provide recommendations in the Policy Implementation Team (PIT) Meeting for prior-authorization and code pends.

+ In collaboration with Code Classification, MD’s and the CMP Leads is responsible for identifying requirements for data analysis to vet new policy concepts assessing the estimated utilization impact and cost savings for the Health Plan of the proposed new policy.

+ Consults with external practitioners, medical professional groups and agencies, professional medical associations, national technology panel and the BlueCross BlueShield Association for advice and expertise in policy development or reassessment as an integral part of medical policy development.

+ Revises drafted medical policies based on CMP Lead recommendations, Medical Director feedback, external physician feedback and research findings. Prepares medical policy drafts for the Medical Director Conference Call (MDCC) and the CMPC. Prepares finalized policies for Medical Director’s approval and posting to the provider facing website.

+ Incorporates line of business (LOB) structure into policy review and development through collaboration and researching of CMS guidelines and eMedNY where applicable and understanding specific regulations and clinical criteria and guidelines.

+ Tracks requests for development of new medical policies working with the CMP Leads and CMP MD’s prioritizing new policy creation and ensuring new policies are created within expected departmental timeframes.

+ Tracks requests for updates to existing policies outside of their normal annual review timeframe working with the CMP Leads to prioritize the requested updates as needed.

+ Provides clinical input by reviewing new CPT and HCPCS procedural coding and ICD-10 Diagnosis coding that pertains to their assigned policies ensuring all assigned policies are updated with new/updated/deleted codes in a timely and accurate manner in collaboration with the CMP Leads and Code Classification.

+ Coordinates all aspects of assigned policy creation and review including collaboration with internal stakeholders for all lines of business of assigned policies.

+ Advises and partners with internal departments as the point person (or SMEs) regarding medical policies.

+ Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.

+ Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.

+ Regular and reliable attendance is expected and required.

+ Performs other functions as assigned by management.

Minimum Qualifications:

+ RN with current New York State license required.

+ Minimum of three years clinical experience in health care required.

+ BSN or advanced degree preferred.

+ Certified Professional Coder (CPC) certification beneficial.

+ Excellent Microsoft Office skillset required.

+ Excellent oral and written communication skills including grammar, punctuation, spelling with the ability to present to a large group required.

+ Excellent organizational skills required.

+ Excellent research skills required including the ability to analyze peer reviewed, medical literature for statistical significance required.

+ Strong knowledge of Health Plan/health insurance products, contract benefits, CPT, ICD10 and HCPCS coding is preferred.

+ Must be highly motivated and able to work independently.

+ Communicate and function effectively as a team member.

Physical Requirements:

+ Ability to work prolonged periods sitting and/or standing at a workstation and working on a computer.

+ Ability to work while sitting and/or standing at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time.

+ Ability to work in a home office for continuous periods of time for business continuity.

+ Ability to travel across the Health Plan service region for meetings and/or trainings as needed.

+ Ability to lift, carry, push, or pull 15 pounds or less.

+ The ability to hear, understand, and speak clearly while using a phone, with or without a headset.

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One Mission. One Vision. One I.D.E.A. One you.

Together we can create a better I.D.E.A. for our communities.

At the Lifetime Healthcare Companies, we’re on a mission to make our communities healthier, and we can’t do it without you. We know inclusion of all people helps fuel our mission and that’s why we approach our work from an I.D.E.A. mindset (Inclusion, Diversity, Equity, and Access). By activating all of our employees' experiences, skills, and perspectives, we take action toward greater health equity.

We aspire for our employees’ interests and values to reflect the communities we live in and serve, and strongly encourage all qualified individuals to apply.

OUR COMPANY CULTURE:

Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing an inclusive workforce, innovative thinking, employee development, and by offering competitive compensation and benefits.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s):

Grade E4: Minimum $65,346 - Maximum $117,622

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

With about 4,000 employees, 31 counties, and serving the needs of over 1.5 million members, you can imagine the gamut of skills it takes to keep our organization growing and our members flourishing. As an internal job seeker, this means growth and development in many directions, divisions, and roles.Take a look at information regarding our hiring process here. https://lifethc.sharepoint.com/sites/HumanCapitalManagement/SitePages/Talent-Acquisition-%26-Onboarding.aspx#hiring-process All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.