Medical Policy Consultant

2 weeks ago

Harrisburg, Pennsylvania, United States Elevance Health Full time

Medical Policy Consultant

National Government Services is a proud member of Elevance Health Companies, Inc. family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare and Medicaid Services to transform federal health programs.

Location: This is a virtual position, and preferred candidates reside within 50 miles of an Elevance Health PulsePoint location.

Shift: Monday - Friday 8 am - 4:30 pm EST.

The Medical Policy Consultant is responsible for researching and drafting NGS Medical Policy ensuring the use of valid and consistent research methodologies.

How you will make an Impact:

  • Conducts structured research within defined methodologies.
  • Drafts and modifies policies using consistent template tools and criteria.
  • Review new and updated codes for accuracy and consistency.
  • Research relevant studies and review articles for the development of local coverage determinations, coverage articles, and coding guidelines and for responses to inquiries from providers.
  • Finalizes issues and ensures implementation of these policies.
  • Works with other internal areas and with the Medical Directors to respond to internal and external requests that seek written clarification of a general or specific policy question. The response may be a reiteration of an established policy a redefinition of the current policy or research to determine a new revised policy.
  • Attendance and understanding of edits via the Edit Effectiveness meetings is a critical skill.
  • Ability to think on your feet and learn the policy consultant job quickly.
  • Scheduling Open Meetings/CACs and informal meeting processes must be learned.
  • Review and respond to OIG, CMS questions, and FOIA requests in a timely fashion.
  • Must be able to formulate a written policy in collaboration with Medical Directors and attend workgroup meetings and weekly CMD/MPU meetings. This must be based on significant research using Hayes and other tools available to the policy team.

Minimum Requirements:

  • Requires a BA/BS degree in a related field and a minimum of 2 years related experience; or any combination of education and experience which would provide an equivalent background.
  • Travels to worksite and other locations as necessary.
  • Working knowledge of coding is required.
  • This position is part of our NGS (National Government Services) division which, per CMS TDL 190275, requires foreign national applicants to meet the residency requirement of living in the United States at least three of the past five years.

Preferred Skills, Capabilities, and Experiences:

  • RN license is preferred.
  • Prior medical literature research experience or related experience is preferred.
  • Technical writing experience preferred.
  • Excellent writing and communication skills and attention to detail as well as a love of research.
  • In-depth knowledge of ICD-10, CPT, and HCPCS codes is preferred.
  • Understanding edits/audits in FISS and MCS is preferred.

If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a `sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role-specific training, monitoring of daily job functions, and sensitive data handling instructions. Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed. The use of this job is limited to the Federal Government Services business unit.

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