Medical Policy Specialist jobs in the United States

Position Description

Serco is seeking a motivated Policy Specialist for Medical Claims Review to join our talented and fast-paced Public Sector Solutions team in supporting CMS’ implementation of the Payment Error Rate Measurement (PERM) Program to produce national Medicaid and Children’s Health Insurance Program (CHIP) improper payment estimates as required by the Payment Integrity Information Act of 2019 (PIIA). As part of this effort, Serco would execute the PERM review contract which includes collection of state eligibility policies and medical records; medical reviews, data processing reviews, and eligibility reviews of selected state Medicaid and CHIP fee-for-services (FFS) and managed care claims; supporting state and national reporting; and development of corrective actions based on review findings.

The Policy Specialist for Medical Claims Review position would support the medical reviews, ensuring updated policy information, interpretation of policy for accurate application of policy to be in compliance with policy and regulation in delivery of PERM program processes and operations. This includes responsibility for overseeing and ensuring that all medical policies are received and maintained in a file and format mutually agreed upon through the review contract. The candidate in this position ideally brings strong subject matter expertise in medical review policies, particularly for the Medicaid and Children’s Health Insurance Program, as well as technical understanding of review or audit processes and information management.

Hybrid or full-time remote work. This is position is contingent on contract award.

In this role, you will:

• Work in direct communication and support of the Assistant Project Director for Medical Review and Medical Review Manager to support key aspects of the PERM Medical Claims Review.
• Track federal Medicaid and CHIP medical policy and regulations
• Support analysis of policy, procedures, manuals, SOPs, and guidance for medical reviews
• Support oversight and compliance to medical policies and review procedures
• Provide technical assistance to state staff and medical reviewers

Competencies 

• Considerable program knowledge of the principles and practices of Medicaid and CHIP program and eligibility policies.
• Ability to interpret Medicaid, CHIP, and state regulations and to analyze their impact on current and proposed programs.
• Demonstrated project management and/or information management skills
• Exceptional interpersonal skills with ability to establish and maintain effective working relationships.
• Ability to communicate effectively, both strong orally and written skills, with government and state stakeholders.
• Enjoy working in fast-paced and collaborative team environment.

Qualifications

It is preferred that the candidate possesses a combination of experience meeting the following criteria:

• Considerable program knowledge of the principles and practices of Medicaid and CHIP
• A work history demonstrating application of knowledge and critical thinking skills, which could include, adjudicating appeals, publishing policy or analysis. writing waiver applications, educating providers, and/or teaching relevant subject matter.
• A minimum of three (3) years of work experience in healthcare policy;
• Preferably familiarity with CPT codes, ICD-9-CM codes, and HCPCS codes; and
• Associate's degree, Bachelor's degree, or Master's degree from an accredited institution and in a field of study that can be reasonably interpreted to perform tasks related to this position.

If you are interested in supporting our mission and working with a passionate team - then submit your application now for immediate consideration.  It only takes a few minutes and could change your career!

Company Overview

Serco Inc. (Serco) is the Americas division of Serco Group, plc. In North America, Serco’s 9,000 employees strive to make an impact every day across 100 sites in the areas of Defense, Citizen Services, and Transportation. We help our clients deliver vital services more efficiently while increasing the satisfaction of their end customers. Serco serves every branch of the U.S. military, numerous U.S. Federal civilian agencies, the Intelligence Community, the Canadian government, state, provincial and local governments, and commercial clients. While your place may look a little different depending on your role, we know you will find yours here. Wherever you work and whatever you do, we invite you to discover your place in our world. Serco is a place you can count on and where you can make an impact because every contribution matters.

To review Serco benefits please visit: https://www.serco.com/na/careers/benefits-of-choosing-serco. If you require an accommodation with the application process please email: careers@serco-na.com or call the HR Service Desk at 800-628-6458, option 1. Please note, due to EEOC/OFCCP compliance, Serco is unable to accept resumes by email.

Candidates may be asked to present proof of identify during the selection process. If requested, this will require presentation of a government-issued I.D. (with photo) with name and address that match the information entered on the application. Serco will not take possession of or retain/store the information provided as proof of identity. For more information on how Serco uses your information, please see our Applicant Privacy Policy and Notice.

Serco does not accept unsolicited resumes through or from search firms or staffing agencies without being a contracted approved vendor. All unsolicited resumes will be considered the property of Serco and will not be obligated to pay a placement or contract fee. If you are interested in becoming an approved vendor at Serco, please email Agencies@serco-na.com.

Serco is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics.