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Resp & Qualifications

PURPOSE:

Ensure that CareFirst is on the cutting edge of medical policy to support and accelerate the emergence of a value-based health care system. Responsible for the thorough research, development, maintenance, and implementation of evidence-based, clinically sound, jurisdictionally compliant corporate medical policy and technology assessments. Represents the Health Services Division on matters of health policy in order to influence subscriber quality medical care and positive relations with providers and the community. We are looking for an experienced clinical leader in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week.

ESSENTIAL FUNCTIONS:

• Responsible for managing the research, development, maintenance and implementation of corporate medical and claims adjudication policies. Collaborates with Medical Directors, Federal, State and Local entities, internally and externally to notify and interpret healthcare policy for new or revised benefit structures. Accountable for managing up to date assessment of both FDA approved and emerging new medical treatment technologies and protocols.

• Accountable for managing corporate systems processes and strategies that involve translation of medical policy into claims adjudication. Collaboratively manages claims software; assess and customize as necessary, and simultaneously on appropriate platforms in collaboration with other departments. Collaborates with internal and external business partners regarding coding practices, policy interpretation and new/existing technology.

• Responsible for supporting Networks Management and contributing to the research, and development, corporate reimbursement policies resulting in consistent claims payment across all platforms, improved provider satisfaction, a reduction in administrative appeals, reduction in interest payments, and a reduction in regulatory complaints.

• Responsible for representing division on matters of healthcare policy in order to influence subscribers, providers and community. Manages the exploration of opportunities and recommending and effecting change for future initiatives or partnerships to improve relationships with internal and external customers.

• Manages the day-to-day activities of the Healthcare Policy, and Technology Assessment Department including managing, coaching, and guiding associates in order to implement departmental, divisional, and organizational mission/goals. Develops annual goals, and prepares, monitors, and analyzes variances of departmental budgets in order to control and appropriately allocate resources.

SUPERVISORY RESPONSIBILITY:

This position manages people.

QUALIFICATIONS:

Education Level: Bachelor's Degree in Nursing or other health related discipline OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Licenses/Certifications:

• Certified Coder (CCS or CPC)-AHIMA or AAPC Required.

• RN - Registered Nurse - State Licensure And/or Compact State Licensure Preferred.

Experience: 5 years' Experience in a health insurance environment, with focus on policy development and implementation; and/or claims operations/medical review experience. 3 years Supervisory experience or demonstrated progressive leadership experience

Preferred Qualifications:

• RN or other clinical background.

• Familiarity with MCG Clinical Guidelines.

• Utilization Management Experience.

• MBA, Healthcare Administration, or related discipline.

Knowledge, Skills and Abilities (KSAs)

• In-depth knowledge and understanding of operational, legal/ethical, and system compliance requirements related to healthcare policy development and implementation.

• In-depth knowledge of standards and laws and regulations related to the health care environment.

• Knowledge of medical and claims policy development.

• Knowledge of reimbursement policy; experience with developing and implementing corporate reimbursement policies to ensure consistent and accurate claims payment.

• Proficiency in Microsoft Office Suite.

• Ability to mentor and coach associates to accomplish goals, provide objective evaluation of associate performance, and implement strategies to improve individual and team-based performance as needed.

• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range: $114,800 - $213,098

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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REQNUMBER: 19933