RN Med Policy Development/Research Specialist - Hybrid

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.


Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week

Onsite: daily onsite requirement based on the essential functions of the job

Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.

This position is hybrid within the state of AZ only. This hybrid work opportunity requires residency, and work to be performed, within the State of Arizona.

PURPOSE OF THE JOB

Perform medical technology research to support the Medical Director Staff and Medical Policy Panel with decisions to ensure that medical policies are consistent with the standards of accepted medical practice in the community.


ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

Level 1

Perform medical technology research related to coverage guidelines and new technology and provide evaluation and summarization to Medical Director Staff and/or Medical Policy Panel
Perform medical technology research as requested by other areas of BCBSAZ thru the Medical Policy Referral Form
Develop and revise coverage guidelines and criteria as requested by management, Medical Director staff or Medical Policy Panel
Communicate medical policy information in protocol format to all areas of BCBSAZ requiring this information
Participate as a contributing member on the Medical Policy Panel providing medical policy issues for discussion and, as required, on the Clinical Coding Governance Committee (CCGC).
Maintain a thorough knowledge of all BCBSAZ medical coverage guidelines and other policies, such as BCBS Association Medical Policy Reference Manual, MCG care guidelines and/or Change Healthcare InterQual, and eviCore criteria.
From the direction of management, Medical Director staff or Medical Policy Panel, facilitate external consultant reviews concerning a coverage guideline or new technology. Responsible for initiating the consultation and providing a summarization concerning the external review to the requestor. Responsible for arrangements for appropriate reimbursement for the consultant’s review.
Communicate medical policy information in protocol format to healthcare providers upon request
With moderate assistance and review by management, perform basic level of code review
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations
Maintain all standards in consideration of State, Federal, BCBSAZ and other accreditation requirements

Level 2

Working independently, recognizes necessity of an external consultant review concerning a coverage guideline or new technology, summarizing and reporting this information to management to facilitate the process as outlined for Level II
With review by management, independently perform intermediate code review with knowledge and understanding of coverage guideline development/revisions with recommendations to the Clinical Coding Governance Committee (CCGC) for integration into benefit programming
Responsible for the training, development and support of grade level I staff under an established training program

Level 3

With review by management, independently perform advanced code review with advanced knowledge and understanding of coverage guideline development/revisions with recommendations to the Clinical Coding Governance Committee (CCGC) for integration into benefit programming.
Working independently, initiate research from resource materials, e.g., clinical journals, periodicals, CMS (Medicare) guidelines and publications, BCBSA publications, other BCBS plans, and internet resources relating to technical, clinical and coverage guidelines, summarizing and reporting this information to management for further action
Responsible for the training, development and support of grade level I and II staff under an established training program

LEVEL 4

Assist manager with the implementation of daily operations with regard to guideline development and revisions, staff supervision, as well as necessary coaching to help each staff member reach personal, professional and department goals
Assist manager with the coordination of all aspects of the Medical Policy Panel and Medical Director Meeting, including preparation, agenda and minutes.
Assist manager with the completion of the monthly, quarterly and annual reporting to Director
Assist manager with the coordination of all aspects of the annual review(s) of MCG, eviCore and/or Change Healthcare InterQual criteria updates
Assist manager with providing oversight to responsible staff for the monthly review of BCBS Association Medical Policy and Reference Manual (MPRM) updates
Assist manager with providing the initial training and instruction for both professional and technical staff and designating the oversight of staff regarding training of new staff at the desk level of instruction/training
Responsible for the training, development and support of grade level III staff under an established training program
Conduct, and/or participate in internal committees that further the goals of BCBSAZ, the Health Services Division and the Medical Policy & Technology Department
Working independently, perform advanced code review with advanced knowledge and understanding of coverage guideline development/revisions with recommendations to the Clinical Coding Governance Committee (CCGC) for integration into benefit programming

ALL LEVELS

Each progressive level includes the ability to perform the essential functions of any lower levels.
The position has an onsite expectation of 1 day per week and requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements
Perform all other duties as assigned.

QUALIFICATIONS
REQUIRED QUALIFICATIONS

Required Work Experience
2 year(s) of experience in clinical field of practice, health insurance, or other health care related field (All Levels)

1 year(s) of experience in medical policy and technology research field (Applies to Level 2)

2 year(s) of experience in medical policy and technology research field (Applies to Level 3)

Required Education

Associate’s Degree in general field of study or Post High School Nursing Diploma or Certification (LPN only) from an approved program (Applies to All Levels)

Required Licenses

Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN, LPN, LPT, LBSW, LMSW, or LCSW. (Applies to All Levels)

Required Certifications

N/A


PREFERRED QUALIFICATIONS

Preferred Work Experience
3 year(s) of experience in clinical field of practice, health insurance, or other health care related field (All Levels)

1 year(s) of experience in claims retrospective review, utilization management, case management, appeals and grievances or quality review field (Applies to All Levels)

Preferred Education
Bachelor's Degree in Nursing or related field of study (Applies to All Levels)

Preferred Licenses
Active, current, and unrestricted State of Arizona (a state in the United States) license to practice as a Registered Nurse (Applies to All Levels)

Preferred Certifications
N/A


COMPETENCIES

REQUIRED COMPETENCIES

Required Job Skills

Intermediate PC proficiency
Intermediate Adobe PDF Standard proficiency
Intermediate word processing, spreadsheet and presentation software proficiency (Applies to All Levels)

Required Professional Competencies

Maintain confidentiality and privacy
Advanced clinical knowledge
Practice interpersonal and active listening skills to achieve customer satisfaction
Compose a variety of business correspondence
Follow and accept instruction and direction
Establish and maintain working relationships in a collaborative team environment
Organizational skills with the ability to prioritize tasks and work with multiple priorities
Independent and sound judgment with good problem solving skills (Applies to All Levels)
Required Leadership Experience and Competencies

N/A

PREFERRED COMPETENCIES

Preferred Job Skills

Advanced PC proficiency
Advanced Adobe PDF Standard proficiency
Advanced processing, spreadsheet and presentation software proficiency (Applies to All Levels)

Preferred Professional Competencies

N/A
Preferred Leadership Experience and Competencies

Participate in strategic planning
Resolve conflicts
Represent BCBSAZ in the community (Applies to All Levels)