Medical Policy and Operational Payment Rules Manager
Job Type :
Direct
Hours :
Full Time
Required Years of Experience :
5-7 years
Required Education :
BA in medical informatics or Nursing
Travel :
No
Relocation :
No
Job Industry :
Healthcare - Health Services
Job Description :
Ensures medical policy development, adoption, communication process and configuration analysis. Ensures timely and proper analysis and update of standards codes, it’s fees and payment rules. Identify opportunities for implementing payment rules that support proper clinical utilization of covered services. Understand medical coding and medical policy. Supports evaluation of BCBSA medical policies and its application to business needs. Reports and oversee medical policies and payment rules impact on utilization. Ensures CMS NCD’s and LCD’s are adopted as per regulatory compliance. Works with other departments to ensure proper clinical and payment policies configuration and programming. Anticipates customer needs and proactively acts to achieve their satisfaction. Responsible for influencing key decisions through recommendations or reviews of rules configuration into Triple S payment and editing systems. Participates in the Priority Committee (PC). Report to the Medical Policy VP on operational matters, quality and resources of the Department
Responsabilities:
- Manages the process for medical policy, including its development, adoption, configuration and communication process.
- Manages the process for payment rules definition and configuration
- Ensures timely and proper analysis and update of standard codes sets, it’s fees and payment rules.
- Identify opportunities for implementing payment rules that support proper clinical utilization of covered services.
- Evaluates, reports and oversee utilization and financial impact of medical policies and payment rules
- Provides a formal mechanism to keep informed internal and external clients on medical policies and payment rules.
- Define and executes a departmental annual work plan that is consistent with the operational goals of the department and the interests of the corporation.
- Distribute staff functions according to the needs of the department.
Required Qualifications :
- Bachelor’s degree in medical informatics, bachelor's degree in Nursing preferably with master’s degree, physician assistant or license eligible medicine doctor or pharmacy doctor.
- Preferably, with a professional certification on medical coding.
- Five (5) to 7 years of experience
- Experience in supervisory functions
