Job Description

Description

: 

JOB SUMMARY

This role supports the Medical Policy team by bringing medical director level expertise, experience and knowledge to the team. They support the full-cycle ownership of commercial and Medicare Advantage medical policies, both developed internally and by vendors. This includes the writing of clinical criteria based on research, engagement of clinical and non-clinical team members for operational guidelines. The incumbent must have an understanding of medical coding (ICD-10, CPT, HCPS) as medical coding based off policy criteria falls within their scope. In addition to developing new policies, the incumbent ensures all existing medical policies, in their scope, are in accordance with NCQA and/or CMS requirements. The incumbent may be required to address escalated inquiries brought forward by internal/external partners. Conducts peer reviews as part of the quality review process. In addition to policy ownership, the incumbent participates in various work-groups and sub-committees as a clinical lead/expert. Trains and orients new staff to the department and policy procedures, and mentors new team members. Serves as a liaison between other departments and vendors as required.


ESSENTIAL RESPONSIBILITIES

  • Full-cycle ownership of commercial and Medicare Advantage medical policy creation process including writing clinical criteria and oversight/ownership of the clinical presentations to committees for internally developed and vendor owned policies.Engage other departments, team members, strategic partners, and vendors to assist with research.

  • Provide clinical guidance to non-clinical team.This may include those who own Medicare Advantage policy updates, and those who support the commercial policy team.

  • Address escalated policy inquiries that require clinical expertise.This may include updating/revising existing medical policies.

  • Partner with Utilization Management and other operational teams to identify opportunities within medical policy.

  • Discover and cultivate innovative opportunities that drive significant improvements in healthcare quality and efficiency.

  • Other duties as assigned or requested.

    • EXPERIENCE

    Required

  • 5 years of Active medical practice

  • 3 years of medical policy experience


    • Preferred

  • 1 year of medical coding experience

    • SKILLS

  • Critical Thinking

  • Oral and Written Communication

  • Listening

  • Telephone Skills

  • General Computer Skills, including Excel

  • Clinical Software

  • Email Software (Outlook) and Teams

  • MS Word

  • Managed Care

    • EDUCATION

    Required

  • Doctor of Medicine or Doctor of Osteopathic Medicine

    • Substitutions

  • None


    • Preferred

  • None


    • LICENSES or CERTIFICATIONS

    Required

  • Medical Doctor OR Doctor of Osteopathic Medicine (DO), Board certified in an American Board of Medical Specialties or Bureau of Osteopathic, Specialists recognized specialty credentialed in a Highmark network

  • Active medical state licensure required. Additional specific state licensure(s) may be required based on business need.


    • Preferred

  • None


    • Language (Other than English):

  • None

    • Travel Required:

  • Less than 25%

    • PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

    Position Type

  • Office-Based or Remote Position

    • Physical work site required

  • Never

    • Pay Range Minimum:

    $170,000.00

    Pay Range Maximum:

    $352,500.00

    Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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