Medical Policy Specialist jobs in Harrisburg, PA

Position Description

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.” 

As a member of Medical Policy & Coding (MPC), the Medical Policy & Coding Consultant I (MPCC1) ensures proper vetting of each medical policy and correct coding structure with oversight from the MPC Lead(s), Medical Policy Consultant 2 (MPC2), and/or management team member(s).

The MPCC1 conducts appropriate medical policy research, reviews Federal/State mandates, and manages assigned medical policy through complete finalization, writing and revision, application of appropriate procedure and diagnosis coding, and compliance with regulatory requirements.

Additional tasks may include, but are not limited to, support of Vendor Programs, New Code, Single Source/Pre-Authorization, special projects, and coding initiatives received throughout the year. Key accountabilities include coding research and identification of CPT, CDT, HCPCS, ICD-10, and revenue codes to meet business needs.

The MPCC1 must develop solid knowledge of regulatory and accrediting requirements and how they relate to medical policy and coding. The MPCC1 works collaboratively with MPC leadership creating, revising, archiving, and implementing Capital Blue Cross medical policy. Works collaboratively with Utilization Management, Medical Directors, Provider Network, IT&D, Appeals & Grievances, Pharmacy, Vendors, and Product to ensure appropriate intent of Capital medical policies and intent of proper payment in accordance with State and Federal requirements/mandates, as well as provider and member contracts.

Responsibilities and Qualifications

• Thoroughly research, develop, and professionally write medical policy utilizing BCBSA resources, other Plan position(s), relevant clinical studies, scientific research, and resources from FDA, specialty specific professional organizations and societies, and other relevant authorities.
• Generate and analyze claims data before and after medical policy review.
• Apply accurate, appropriate procedure and diagnosis coding to each medical policy.
• Assess and recommend opportunities related to cost-efficiency to mitigate risk through ongoing collaboration with internal stakeholders. Ensure Medical Policy hand-off occurs for circulation.
• Ensure assigned Medical Policies are completed timely to meet Clinical Advisory Committee, Configuration/Pre-Configuration/Consensus circulation and publication goals.
• Develop a working understanding of Facets Claims System, SharePoint and MS Office software.
• Assist in the development of the department’s processes, policies and procedures.
• Ensure Vendor Program medical policies and procedures are correct and reviewed routinely (at least annually) to ensure compliance.
• Participate in departmental tasks, such as, New Code, Single Source, implementation of ICD10, timely completion of inquiries, and other procedure code implementations.
• Actively engage in identification and implementation of process improvement activities.
• Review data and provide recommendations for Reimbursement Policy opportunities.
• Participate as a team member in initiatives and other tasks as assigned.

Skills:

• Demonstrated proficiency of researching, analyzing, and presenting data.
• Demonstrated ability to communicate effectively and professionally in written and verbal form with internal stakeholders and ensure quality of both communications including, but not limited to, formatting, spelling, punctuation and grammar and excellent proof and edit skills.
• Demonstrated exceptional organizational skills and attention to detail.
• Knowledge of Centers for Medicare Services (CMS), FEP, NCQA, DOH and partnering insurance plans policies and regulations. Ability to organize work and complete assigned work schedule and set priorities with minimal direct day-to-day supervision.
• Ability to adjust to changing job requirements and priorities to meet dynamic needs and workflow.
• Review Medical Policy and collaborate with Medical Policy writer in order to formulate a robust clinical position representing Capital Blue Cross’ position and appropriate plan coverage for each member.
• Demonstrated proficiency in Microsoft Office Suite including but not limited to Outlook, Word, Excel, PowerPoint & Access. Working knowledge in SharePoint a plus.
• Demonstrated ability to perform basic arithmetic, percentage, and statistical calculations.

Knowledge:

• Current, working knowledge of clinical practice and/or health research.
• Working knowledge of medical coding, to include, ICD10, CPT, CDT, HCPCs and revenue codes.
• Working knowledge of Government regulatory and accrediting requirements (PPACA, FEP, CMS, Pennsylvania state regulations, NCQA, URAC, DOH and Medical Assistance).
• Advanced understanding of Medical Terminology.

Experience:

• Strong clinical, policy, or research background; 3-5 years’ experience.
• Minimum of 3 years’ similar work experience, preferably in a managed care /health insurance related position.
• Proficient in Microsoft Office Suite: Word, Excel, PowerPoint
• Experience in use of SharePoint strongly desired.

Education and Certifications:

• Current, non-restricted clinical license
• The position requires obtaining an American Association of Professional Coders (AAPC) Medical Coding certification. The AAPC certification course will be offered at management’s discretion once the employee meets certain criteria showing course readiness. Continuing education credits must be satisfied to maintain the certification. If the AAPC certification is not obtained successfully, it could result in termination.
• Bachelor’s degree, preferred

Physical Demands:

• The employee is frequently required to sit, use hands and fingers, talk, hear, and see.
• The employee must be able to physically sustain a work week sometimes exceeding 40 hours per week.
• The employee must occasionally lift and/or move up to 5-10 pounds.
• 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