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Clinical Policy Research Specialist

3 weeks ago

Saint Paul, Minnesota, United States Elevance Health Full time

Job Summary

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We are seeking a skilled Clinical Policy Research Specialist to join our team. In this role, you will be responsible for conducting research and analyzing medical policies to support Oncology Solution. Your expertise in medical research and policy development will be crucial in ensuring that our policies align with local and national Medicare guidelines.

Main Responsibilities:

  • Researches and evaluates medical claim issues against local and national Medicare policy guidelines.
  • Reviews new and updated codes for accuracy and consistency.
  • Conducts literature reviews and analyzes relevant studies to inform the development of local medical review policies.
  • Analyzes and interprets CMS guidelines, NCCN, and other compendia's to ensure compliance.
  • Collaborates with Medical Directors and pharmacists to develop local medical review policies.
  • Reviews complex and non-standard claims to ensure accurate processing and clinical appropriateness.
  • Codes changes into claims systems using national coding structure.
  • Serves as a liaison to business units for correct coding of claims.
  • Researches questions and issues from internal physicians and nurses as they relate to developed medical policies.
  • Responds to internal and external requests for written clarification of general or specific policy questions.

Requirements:

  • Requires a BA/BS degree and a minimum of 2 years related experience including clinical experience and may include operations experience; or any combination of education and experience which would provide an equivalent background.
  • Requires active state RN license.