Medical Policy Jobs (NOW HIRING)

Pay Range:

Please emailHR_Talent_AcquisitionTeam@bcbsri.orgif you are a candidate seeking a reasonable accommodation for the application and/or interview process.

At BCBSRI, our greatest resource is our people.

We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Passion, empathy, and understanding are at the forefront of everything we do-not just for our members, but for our employees as well.

We recognize that to do your best work, you have to be your best self.
It's why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health, dental, and vision insurance as well as programs that support your mental health and well-being. We pay competitively, offer bonuses and investment plans, and are committed to growing and developing our employees.

Our culture is one of belonging.
We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where you're at in the organization, you're an integral part of our team and your input, thoughts, and ideas are valued.

Join others who value a workplace for all.
We appreciate and celebrate everything that makes us unique, from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders.

We're dedicated to serving Rhode Islanders.
Our focus extends beyond providing access to high-quality, affordable, and equitable care. To further improve the health and well-being of our fellow Rhode Islanders, we regularly roll up our sleeves and get to work (literally) in communities all across the state-building homes, working in food pantries, revitalizing community centers, and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can, our associates receive additional paid time to volunteer.

Why this job matters:

Develop and evaluate the effectiveness of company medical and administrative policies. Research and develop new policies as well as changes to existing policies on a regular basis. Perform industry evaluations/benchmarking of BCBSRI policies to industry standards. Work with other internal business and clinical associates and medical directors in the development and approval of both new, and updates to, existing policies. Ensure internal training materials and external provider documentation is consistent with company policies and state and federal guidelines and/or accreditation requirements. Coordinate and organize quarterly new code releases from the American Medical Association and Centers for Medicare and Medicaid Services.

What you will do:

• Evaluate effectiveness of company medical and administrative; serve as internal and external contact for inquiries related to policies. Work closely with medical staff to review existing policies and develop recommendations for new policies.

• Ensure adherence to corporate timelines and quality standards for creating new policies and reviews of existing policies, while adhering to applicable state and federal guidelines, accreditation agencies (e.g. NCQA, as well as Centers for Medicare and Medicaid Services (CMS)) requirements and guidance.

• Direct internal areas in the development and implementation of policies. Provide education to staff regarding policy administration.

• Administer research for quarterly new code releases and coordinate workgroups of stakeholders to obtain coverage determinations necessary for implementation of code sets.

• Participate in department initiatives and projects. Serve as department representative and participate on projects related to company medical, administrative, and some reimbursement policies.

• Maintain provider manuals and internal training materials; ensure materials are consistent with policies and state and federal guidelines.

• Establish criteria for the financial impact analysis of policies; collaborate with internal areas to obtain financial data. Participate in the testing and creation of business requirements for the system request process. Monitor status reports to ensure timely implementation and communication (internal and external) of system changes.

• Perform other duties as assigned.

What you need to succeed:

• Bachelor's Degree in Nursing, Business Administration, Healthcare Services or related field, or an equivalent combination of education and experience

• Three to five years of experience in medical policy review, quality management or an analytical discipline

• Certified Professional Coder (CPC) Certification

• Proficiency with Microsoft Suite of products (i.e., Word, Excel, PPT, etc.)

• Proficiency in web-based searching and CMS website navigation

• Medical policy and benefit knowledge

• Knowledge of medical terminology and claims payment policies including applicable coding methodology

• Advanced analytical skills, with the ability to interpret and synthesize complex data sets

• Good business acumen and political savvy

• Knowledge of business process improvement techniques and strategies

• Ability to work independently or as an active member of a team

• Accurate and precise attention to detail

• Ability to multitask, prioritize, and manage time efficiently

• Excellent verbal and written communications skills

• Negotiation skills

• Presentation skills

• Decision-making skills

• Problem-solving skills

• Ability to interface with employees at all levels

• Ability to effectively navigate ambiguous situations with limited direction

• Excellent organizational skills and ability to successfully prioritize multiple tasks

• Ability to handle multiple priorities/projects

The extras:

• Contract knowledge and knowledge of provider risk arrangements

• Knowledge of managed benefits strategies, utilization review techniques, healthcare financing and delivery

Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:

• In-office: onsite 5 days per week
• Hybrid: onsite 2-4 days per week
• Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia
  

Our culture of belonging at Blue Cross & Blue Shield of Rhode Island (BCBSRI) is at the core of all we do, and it strengthens our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity employer.

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