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:
$170,000.00Pay Range Maximum:
$363,100.00Highmark 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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Medical Director, Medical Policy • NM, Working at Home, New Mexico
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