Nurse - Medical Policy Clinician

Job ID: J114789
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at:

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Description

JOB SUMMARY

This job owns the full-cycle commercial medical policies, both developed internally and by vendors.  This includes the writing of clinical criteria based on research, engagement of non-clinical team members for operational guidelines,  and ownership of the publishing process.  The incumbent must have an understanding of medical coding (ICD-10, CPT, HCPS) as medical coding based off of policy criteria falls in their scope.  In addition to developing new policies, the incumbent ensures all existing medical policies, in their scope, are up to date which may involve revisions in response to 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 on various work-groups and sub-committees as clinical leads/experts.  Trains and orients new staff to the department and policy procedures, and mentors new team members.  Serves as a liasion between other departments and vendors as required.

ESSENTIAL RESPONSIBILITIES

  • Full-cycle ownership of the commercial medical policy creation process including writing clinical criteria and oversight/ownership of the clinical presentations to committees and publication process for internally owned and vendor owned policies.  Engage other departments, team members, and vendors to assist with research, the development and communication of operational guidelines, and aspects of publication.  
  • Provide clinical guidance to non-clinical team.  This may include those who own Medicare Advantage policy owners, and those who support the commercial policy group.
  • Address escalated policy inquiries that need clinical expertise.  This may include updating/revising existing commercial policies.
  • Other duties as assigned.

QUALIFICATIONS

Required

  • Bachelor's degree in Nursing, Pharmacy or Psychology or 6 years of health care experience or alternative clinical education can be substituted in lieu of bachelor's degree.  
  • 3 - 5 years of Healthcare Experience
  • 1 - 3 years of Medical Policy

Preferred

  • 1 - 3 years of Medical Coding

LICENSES OR CERTIFICATIONS

Required

  • Registered Nurse
  • Certified Registered Nurse Practioner
  • Registered Pharmacist
  • Licensed Social Worker (LSW)-Non-Specific

SKILLS

  • Oral & Written Communication Skills
  • Telephone Skills
  • Problem Solving & Decision Making
  • Compliance
  • Healthcare Industry
  • Health Insurance
  • Mentoring

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 their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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