Medical Policy Implementation Consultant

Job Description

How is This Role Important to Our Work?

This position a key member of the team that develops and implements medical policies for Client.The incumbent will be responsible for ensuring that medical policy issues are circulated to internal stakeholders of the company at several stages before final implementation.The incumbent will be part of a team that ensures policies are implemented and integrated with all systems to ensure accurate claims processing.This will include reviewing and applying new codes to the medical policies, developing quality improvement processes for medical policy implementation, and assisting with data reporting needs, as they pertain to the policy decision making process.The incumbent will also organize communication of medical policy changes and serve as a liaison, within the Integrated Health Management division, for communication of medical policy issues.The Senior Medical Policy Consultant serves as a resource to other members of the Medical Policy team.Team is implementing an automation tool that codifies medical policies and utilizes AI to automate prior authorization approvals where possible.

A Day in the Life

Support AuthAI ImplementationClinical decision tree validation, by comparing clinical decision tree to medical policy, to ensure alignmentTesting support once AuthAI is implementedPresent and provide implementation input to key medical policy committees: Medical and Behavioral Health Policy Committee, Coverage Committee, and Operational committees as assigned for example, Coding and Reimbursement Committee, and Medical Policy Prep CommitteesPrepare final policy documents and tools for implementation.Implement medical policies-integrates with all systems to ensure accurate claims processing.Assure that changes in Client medical policies are communicated to all lines of business, including Medicare, and others as needed.Research and apply appropriate and regular updates of CPT, HCPCS, and ICD-9/ICD-10 coding to the medical policies.Maintain Client intranet and internet medical policy databases with current policy decisions and coding.Produce standard reports and assist in the analysis and impact of these reports as they relate to policy implementation process.This will require training in several Client systems such as MCS, ViPS STARS and others as necessary.Serve as a liaison to other divisions (e.g., Network Management, Account Management, and Service) for medical policy issues.Research issues on an ad hoc basis to determine coverage status of other health plans, FDA approval status; this may also require limited research of evidence-based literature.Lead work groups as needed.Lead projects that support Medical Policy Department and/or Medical Affairs Department.Serve as a subject matter expert to team members and Client.

Required Skills and Experiences

5+ years of related professional experience. All relevant experience including work, education, transferable skills, and military experience will be considered.Registered Nurse with strong understanding of medical policy interpretation as it relates to prior authorization processingAbility to apply critical thinking skills to medical policy interpretation and implementation.Ability to work independently; well-organized and able to set priorities with minimal direction.Ability to effectively communicate both verbally and in writing.Strong PC skills; Excel, PowerPoint, Visio, Word, and internet based programs.Ability to develop and work on several projects at one time in a fast paced environment.Ability to maintain relationships with internal and external stakeholders, clinicians, and others.Project management experience.Demonstrated positive professionalism in all work-related behaviors as demonstrated by adaptability, contributing to team success, customer focus, skillful communication, and efficiently managing work.

Nice to Have

Bachelor's or Masters degree in a health-related field, such as nursing.