Medical Policy and Coding Consultant at Capital BlueCross in Harrisburg, Pennsylvania

Job Description:

As a member of the Medical Policy & Coding Unit (MPC), the Medical Policy & Coding Consultant I (MPCC1) is responsible to ensure proper vetting of each medical policy and correct coding structure with oversight from the MPC Lead, MPC2 or management team member(s). This includes ensuring accurate medical policy is published by conducting appropriate medical policy research, review of Federal/State mandates, management of assigned medical policy through complete finalization, professional writing, applying appropriate procedure and diagnosis coding and ensuring compliance with regulatory requirements. Additional tasks include, but are not limited to, support of Vendor Programs, New Code, Single Source, special projects and coding initiatives received throughout the year. Key accountabilities include coding research and identification of CPT, CDT, HCPCS, ICD-10 and revenue codes to meet business needs and solid knowledge of regulatory and accrediting requirements and how they relate to medical policy and coding.

Responsibilities include, but are not limited to, working collaboratively with MPC leadership creating, revising or archiving Capital Blue Cross medical policy. Expectations include researching medical literature and interpretation of statistical data/studies, monitoring for trends/patterns/changes in medical care, completing a comparison review of local/competitor plans consideration of benefit position, coding medical policy with appropriate procedure and diagnosis codes and providing implementation guidance of existing and newly created medical policy. This position will generate and analyze claim reports to include an impact assessment to all lines of business (LOB) and will mitigate internal stakeholder concerns. Also, review of post policy publication claims to ensure payment is correct based on administration of benefits and to ensure regulatory compliance. Working knowledge SAS Reporting, Microsoft Office, SharePoint, Facets, Capital Blue Cross claims adjudication processes and customer purchased benefits to include both private sector and FEP/governmental business is required.

The MPC1 participates in both internal and external committee activities requiring the ability to clearly and accurately present medical policy, articulate the clinical position, document issues/decisions, and provide timely follow-up. This includes, but is not limited to, Clinical Advisory Committee Meeting (CAC), Pre-Configuration Meeting, Configuration Meeting and Utilization Management Meeting.

This position requires various skills, such as, good analytic qualities and attention to detail, critical thinking and problem solving ability. The MPC1 possesses the ability to communicate professionally, respectfully and effectively both verbally and in writing. Good organizational skills and maintaining confidentiality are required. This position is also accountable for the knowledge and execution of the CBC Standards of Conduct and working within the Fit for Excellence model related to departmental benchmark metrics. This position requires flexibility to perform other duties as assigned.

ESSENTIAL DUTIES & RESPONSIBILITIES

• Thoroughly research, develop and professionally write medical policy utilizing the BCBSA, other Plan position(s), relevant clinical studies, scientific research, FDA, specialty specific professional organizations and societies, generate and analyze claims data before and after medical policy review.  Apply accurate, appropriate procedure and diagnosis coding to each medical policy.  Forward focus assessing and recommending opportunities related to cost management initiatives to mitigate risk through ongoing collaboration with internal stakeholders.  Ensure Medical Policy hand-off occurs for circulation.


• Ensure assigned Medical Policies are completed timely to meet Clinical Advisory Committee, Configuration/Pre-Configuration/Consensus circulation and publication goals.


• Working understanding of Facets Claims System, SharePoint and MS Office software.


• Ensure Vendor Program medical policies and procedures are correct and reviewed routinely (at least annually) to ensure compliance.


• Participates in departmental projects, such as, New Code, Single Source, implementation of ICD10, timely completion of inquiries and other procedure code implementations.


• Assist in the development of the department’s processes, policies and procedures.


• Participate as a team member in initiatives and projects as assigned.


• Actively engage in identification and implementation of process improvement activities


• Utilizes communication skills to accurately communicate recommended medical policy, coding or project actions clearly and concise. 


• Demonstrates strong proof-reading and editing skills for all job tasks.


• Identify and recommend process improvement activities.


• Ability to organize work tasks, attend meetings, manage time effectively.


• Demonstrated ability to handle information in a confidential manner (HIPAA)


• Recognizes and understands corporate requirements as outlined by Corporate Compliance initiatives and apply to daily work routine.


• Reviews data and provides recommendations for Reimbursement Policy opportunities.


• Perform other related duties as assigned.

JOB REQUIREMENTS

Education, Certification, and Licenses:

• Current, non-restricted clinical license within the Commonwealth of PA.


• Medical Coding certification CPC and/or COC, preferred; if not, will schedule and complete AAPC certification within one (1) year of hire.


• Bachelor’s degree, preferred.


• Current valid Pennsylvania driver’s license

Experience: 

• Minimum of 3 year’s similar work experience, preferably in a managed care /health insurance related position.  Proficient in Microsoft Office Suite; Word, Excel, PowerPoint.

Skills:

• Strong Clinical background; 3-5 years’ experience.


• Knowledge of Capital Blue Cross benefits and medical policy.


• Demonstrated proficiency of medical procedure and diagnosis coding knowledge.


• Demonstrated proficiency of analyzing and presenting data (both claims and published literature).


• Demonstrated ability to communicate effectively in written and verbal form with internal stakeholders and ensure quality of both communications including, but not limited to, formatting, spelling, punctuation and grammar and excellent proof and edit skills. 


• Demonstrated ability to communicate effectively professionally, respectfully in written and verbal form with both internal and external customers.


• Demonstrated exceptional organizational skills and attention to detail.


• Knowledge of Centers for Medicare Services (CMS), FEP, NCQA, DOH and partnering insurance plans policies and regulations.


• Knowledge of acceptable office practice and procedure including appropriate form and format of medical and business correspondence and reports.


• Ability to adjust to changing job requirements and priorities in order to meet dynamic needs and workflow.


• Review Medical Policy and collaborate with Medical Policy writer in order to formulate a robust clinical position representing Capital Blue Cross’ position and appropriate plan coverage for each member.


• Demonstrated proficiency in Microsoft Office Suite including but not limited to Outlook, Word, Excel, and PowerPoint & Access.  Working knowledge in SharePoint a plus.


• Demonstrated ability to perform basic arithmetic, percentage and statistical calculations.


• Ability to organize work and complete assigned work schedule and set priorities with minimal direct day-to-day supervision.

Knowledge:

• Strong, current, working knowledge of medical practice.


• Strong working knowledge of medical coding, to include, ICD10, CPT, CDT, HCPCs and revenue codes.


• Strong working knowledge of Government regulatory and accrediting requirements (PPACA, FEP, CMS, Pennsylvania state regulations, NCQA, URAC, DOH and Medical Assistance).


• Advanced understanding of Medical Terminology.


• Knowledge of IT&D, pre-configuration and configuration and various steps to compose and circulate a medical policy to completion as needed.


• Strong knowledge of medical coding including, ICD10, CPT, CDT, HCPCS and revenue codes.

Physical Demands: The employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must be able to physically sustain a workweek sometimes exceeding 40 hours per week. The employee must occasionally lift and/or move up to 5-10 pounds.

This position requires signing the Non-Disclosure, Non-Solicitation and Non-Competition Agreement.

Capital BlueCross is an independent licensee of the BlueCross BlueShield Association. We are an equal opportunity/affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.