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Medical Policy Registered Nurse, Senior (Telecommuter)

Blue Shield of California El Dorado Hills, CA
  • Posted: July 12, 2019
  • Full-Time
Job Title: Medical Policy RN (TELECOMMUTER ROLE)


This position will be part of the Medical Policy Team in the Medical Care Solutions Organization.


Job Functions Include:
  • Perform clinical research through all available resources to ensure current and accurate information is used in policy revisions or development. 
  • Ongoing development of the Medical Policy review process including clinical and utilization data analysis.
  • Produce a policy that is operationally ready for implementation in Medical Care Solutions Organization.
  • Assist in documenting end-to-end process for policy development including communication, roles, department standards, workflows, and data management.
  • Identify procedures for pre-service, post-service and/or benefit changes, thus gaining efficiencies and easing the provider and member experience.
  • Establish working relationships with, and facilitate stakeholder input in assessing all impacts of Medical Policy decisions
  • Attend and participate in all meetings related to policy development, discussion and operational implementation of medical policies.
  • Assist in developing training documents and presentations for new and/or revised Medical Policies to internal stakeholders. 
  • Work closely with the RNs in Medical Operations to understand current workflow based on what is considered medically necessary, not medically necessary or investigational
  • Identify discrepancies and provide operational feedback to project team based on the findings
  • Identify efficiencies in reduction of unnecessary medical record request, prior authorization review or claims review.

Education/Experience:
  • Requires current CA RN License
  • Bachelor of Science Degree in Nursing preferred
  • Proficient knowledge of NCQA, URAC, federal and state requirements
  • Requires 3-4 years of acute clinical experience and at least 5 years of Health Plan, ASO or IPA/Medical Group experience
  • Familiarity with UM functions and understanding of BSC book of business preferred
  • Proficient in program operations and metrics
  • Proficient in using Microsoft Word, Excel and some basic understanding of Microsoft Access database
  • Previous Medical Policy Development experience preferred

Blue Shield of California

Address

El Dorado Hills, CA
USA

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