Coordination of all activity associated with the development and maintenance of medical policy and benefit interpretation in accordance with BCN certificates, riders, waivers, statewide policies and with BCBSM policies and procedures. Investigation of new procedures, technology, drugs and devices. Maintenance of clinical documentation related to new technologies and treatment modalities, including BCN's position of coverage of these items/services/treatments. Communication to and education of team members, including physician advisors regarding new technologies, treatment modalities, drugs and devices with an emphasis/focus on BCN's policy and benefit determination. Coordination of all requests related to solid organ transplants (other than kidney, skin and cornea) and for bone marrow transplants, as well as for services that are potentially experimental or investigational.
Proactively identify and evaluate documentation on new treatments and technologies for potential coverage determinations by BCN and/or BCBSM for all lines of business.
Develop policy(ies) for new treatments or technologies for presentation to the Joint Uniform Medical Policy (JUMP) Committee or the BCN Medical Management Committee.
Maintain documentation supporting medical policy and benefit interpretation decisions, including for use in communications - both internal and external.
Develop and maintain a resource base for investigative and research activities, resources which may include the FDA, TEC, BCBSA, etc., to facilitate collection of additional technology assessments and its application to medical policy.
Research and compile documentation to substantiate medical policy determinations and benefit interpretations in accordance with BCNM certificates, riders, and waivers, as well as Blue Choice and CMS guidelines.
Initiate internet and medical literature searches to be utilized by medical policy, care management, quality management, pharmacy management or other areas, as needed.
Respond to inquiries from team members and other departments, as well as complex inquiries from PCGs/PCPs, ensuring appropriate and consistent benefit interpretation.
Coordinate benefit issues with the committee chairperson to assure that relevant issues are added to the Medical Management Committee meeting agenda - facilitating uniform benefit interpretation.
Collect and coordinate the distribution and/or provision of information to be reviewed by JUMP, the Medical Management Committee and/or the Medical Director(s) for medical policy determination and benefit interpretation statements, including drafts of joint and/or BCN policies. Develop and maintain a network of contact people within the BCN network, BCBSM and BCBSA, as well as external vendors, to facilitate timely and consistent medical policy development and benefit interpretation.
Collect and review documentation related to case requests, e.g., transplants, experimental/investigational.
Prepare and present said cases for review by the BCN/BCBSM Medical Director as indicated. Cases to be documented in accord with established processes.
Review and coordination of claims; specifically multi-line surgery claims, benefit-related claims issues and claims requiring review of medical records; to ensure prompt and accurate claims processing.
Other duties as assigned by Care Management leadership.
"Qualifications"
Registered nurse (RN) with current valid Michigan license required
Bachelor's degree required, major in nursing or other health care related field preferred. OR Associate's degree or two years of full-time college credits and one (1) year of utilization/quality management experience in addition to the experience listed below for each year towards a Bachelor's degree lacking required.
Four (4) years broad clinical experience required
Three (3) years experience in utilization management and/or quality management required, preferably within a managed care environment
Two (2) years experience in medical policy or benefit determinations preferred.
Excellent verbal and written communication skills required
Excellent organizational skills and self-starter with the ability to handle multiple projects and timelines including planning and development required.
Excellent interpersonal skills including the ability to work as part of a team and interact with internal and external customers and all levels of the organization required.
Ability to work independently with minimal direction required.
Excellent problem solving, research, analytical, and decision-making skills required.
Intermediate knowledge of Microsoft Word required.
Knowledgeable of current medical and clinical practices, including community standards of practice, and benefit determination as related to medical treatment issues required.
Knowledge of Facets and CarePlanner preferred
Detailed knowledge of BCN policies and procedures BCN Member Certificates, including riders, waivers, exclusions and limitations preferred
Knowledge of CMS benefit guidelines preferred
Knowledge of BCN's medical management processes, reimbursement policies, utilization management policies and procedures, and claims processing flow preferred
Knowledge of BCBSM medical policies and procedures, claims processing flow, and utilization management policies and procedures preferred
Knowledge of NCQA, CMS, State and Federal HMO regulations preferred
Technical writing skills preferred
Knowledge of Microsoft Excel and Access preferred.
All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.
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