RN Medical Policy Supervisor

E-mail mike.foster@rightthinginc.com for more information!

Highmark would prefer this candidate in Pittsburgh, PA but would also consider someone in Wilmington, DE, Camp Hill, PA, or Charleston, WV

• This position is responsible for monitoring, analyzing, comparing, and evaluating medical policy content and application for all Highmark products, and making recommendations, as necessary, to achieve objectives established by Highmark management.
• To this end, the incumbent must analyze a wide array of data, including Highmark policy application, procedure codes and modifiers, utilization, reimbursement, Blue Cross Blue Shield Association (BCBSA) policy/procedure codes, and other information, taking into account product differences, lines of business, and processing systems (e.g., OSCAR), etc. This requires coordination of information and activities with counterparts in Health Affairs, OSCAR Coding Solutions, Provider Relations, Senior Markets, Product Management, Regulatory, Compliance, Legal, and other external personnel.
• The incumbent is also responsible for supervising and directing a section of employees in the development and maintenance of medical policy used by the Corporation. This includes delegation of assignments, technical guidance, training, recommendations on personnel needs and preparation of performance appraisals including recommendations on performance ratings.
• In addition, the position has accountability for special projects and enhanced research activities within the department.
• To effectively fulfill the accountabilities of this position, the incumbent must demonstrate a thorough knowledge of medical policy, product lines, procedure codes, reimbursement, managed care, as well as a comprehensive understanding of medical terminology, BCBSA medical policy, Centers for Medicare and Medicaid Services (CMS) guidelines, the HCFA Common Procedure Coding System (HCPCS), International Classification of Disease (ICD) information, TeamSite, and Highmark and external processing systems.
• This position requires a thorough knowledge and understanding of the clinical aspects of the evaluation of new and existing medical technology.
• This requires skill in utilizing the Internet and various databases to do clinical research and analysis.
• The position also requires excellent analytical, problem-solving, decision-making, critical thinking, and verbal/written communication skills.
• In addition to sophisticated technical knowledge, the incumbent must demonstrate strong interpersonal skills and the ability to motivate and direct a professional staff.
• An R.N. degree is preferred, but not required.
• Some travel may be required.

REQUIRED QUALIFICATIONS:

Education level and/or relevant years of experience(s) in lieu of education:

• Bachelors degree
• Five (5) years combined experience in commercial claims and/or medical/surgical products or Medicare Advantage or Medicare Fee for Service program coverage

PREFERRED QUALIFICATIONS:

• Master's degree

Additional relevant knowledge and/or skills and/or work experience:

• Three (3) to five (5) years of experience in clinical research
• Ability to analyze CMS documents such as transmittals and the Federal Register
• Excellent verbal and written communication skills because of the interaction with various internal departments, as well as communications with physicians, state specialty societies, etc.
• Knowledge of OSCAR claims processing system
• Well developed computer skills using web search engines for clinical literature and clinical trials
• Independent assessment and excellent time management skills are necessary components of the multi-tasking accountability
• Excellent planning and organization skills
• Excellent critical/analytical skills
• Three (3) to five (5) years of supervisory experience
• Three (3) to five (5) years of project management experience

Additional relevant licenses, certifications, training, etc:

• Certified Professional Coder

Highmark is an Affirmative Action/Equal Employment Opportunity (AA/EEO) employer.