Medical Policy Nurse - First Coast Service Options
Are you interested in joining a team of experienced healthcare experts and have the ability to shape and transform the healthcare delivery system? At our family of companies, everything we do is to help improve the lives of the nearly 12 million Medicare beneficiaries we serve and 700,000 health care providers who care for them. It is our goal to help create a better health experience for all consumers. Join our winning culture and help transform Medicare for the millions of people who rely on its services.
Benefits info:* Medical, dental, vision, life and supplemental insurance plans effective the first day of the month following date of hire* Short- and long-term disability benefits* 401(k) plan with company match and immediate vesting* Free telehealth benefits* Free gym memberships* Employee Incentive Plan* Employee Assistance Program* Rewards and Recognition Programs* Paid Time Off and Paid Sick Leave
SUMMARY STATEMENTThis position is responsible for the development and maintenance of Local Coverage Determinations (LCDs) and Local Coverage Articles (Articles) in accordance with the CMS regulations and requirements and has a direct impact in ensuring access to care for Medicare beneficiaries, ensuring claims are paid correctly, and in safeguarding the Medicare trust fund.
ESSENTIAL RESPONSIBILITIESTo perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.
Development and Maintenance of LCDs and Articles: (80%)* Working in close collaboration with the Contractor Medical Directors and other members of the Medical Affairs team, responsible for the timely and accurate creation and revision of LCDs and Articles in accordance with CMS regulatory guidance and requirements, especially those found in the Medicare Program Integrity Manual Chapter 13, to include all the following:o Development and maintenance of new LCDs and Articles, including thorough review, analysis, and summary of the following: claims data, pertinent CMS instruction, available evidence, including but not limited to published medical literature, discussion with Contractor Advisory Committee (CAC) members, subject matters experts (SMEs), Medicare providers etc., correct coding and billing requirementso Review of Reconsideration Requests and completion of appropriate resulting LCD revisions o Annual and other mandatory updates (e.g., diagnosis and procedure codes, Change Requests, etc.)o Development and maintenance of accessible electronic LCD and Article files o Participation in the formal, external Open Meetings and CAC meetings including creation and presentation of information specific to assigned LCDso Review and revision of departmental procedures related to LCD development and revisions. Subject Matter Expert (SME): (20%)* Serves as point of contact for internal operations regarding medical coverage and coding questions.* Collaborates with edit team to ensure appropriate edits are created in keeping with the LCD instruction.* Serves as SME for assigned LCDs and Articles and interfaces with technical, professional, and clinical personnel; routinely interacting with all levels of staff in the company, including the Executive Medical Directors, as well as other senior leaders.* Attends regularly scheduled internal meetings to ensure adequate information sharing and education as appropriate throughout the company regarding LCDs and Articles. * Accountable for regular and ongoing communication with external customers, including but not limited to, CMS, local and national medical societies/associations, stakeholders, other professional organizations, and Medicare providers, to ensure adequate information sharing and education regarding LCDs and Articles.* Routinely and proactively collaborates with team members including the CMDs, senior leadership, and operational leads as necessary to identify and implement improvements related to the policy development process.
Performs other duties as the supervisor may, from time to time, deem necessary.
REQUIRED QUALIFICATIONS* High School Diploma or GED * 3 years' related work experience; this includes 2 years of Medicare experience and 1 year of health insurance coding (e.g., ICD-10, CPT/HCPCS) experience* Proficient in research of the CMS Internet-Only manual (IOM) and national and local coverage decisions* Proficient in MS Office applications and Internet research * Comprehensive knowledge of medical, surgical and diagnostic procedures and terminology* Excellent written and oral communication skills* Ability to communicate with confidence with other medical professionals, Medical Societies, Medicare providers, CMS and Contractor Advisory Committee (CAC) members * Professional demeanor and positive approach to work* Excellent planning, organizing, time and work management skills* Ability to travel
CERTIFICATIONS, LICENSES, REGISTRATIONS* Valid unrestricted Registered Nurse (RN) license
PREFERRED QUALIFICATIONS* Bachelor's degree in Nursing * 5 or more years of clinical experience as a Registered Nurse* 3 or more years of Medicare experience * 3 or more years of experience in Health or Business Administration* 3 or more years of health insurance experience in operations, claims review, case review, education, and/or medical and payment policy * 3 or more years of health insurance coding (e.g. ICD-10-CM, CPT/HCPCS)* Certified Professional Coder (CPC) certification/credential
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Benefits info:* Medical, dental, vision, life and supplemental insurance plans effective the first day of the month following date of hire* Short- and long-term disability benefits* 401(k) plan with company match and immediate vesting* Free telehealth benefits* Free gym memberships* Employee Incentive Plan* Employee Assistance Program* Rewards and Recognition Programs* Paid Time Off and Paid Sick Leave
SUMMARY STATEMENTThis position is responsible for the development and maintenance of Local Coverage Determinations (LCDs) and Local Coverage Articles (Articles) in accordance with the CMS regulations and requirements and has a direct impact in ensuring access to care for Medicare beneficiaries, ensuring claims are paid correctly, and in safeguarding the Medicare trust fund.
ESSENTIAL RESPONSIBILITIESTo perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.
Development and Maintenance of LCDs and Articles: (80%)* Working in close collaboration with the Contractor Medical Directors and other members of the Medical Affairs team, responsible for the timely and accurate creation and revision of LCDs and Articles in accordance with CMS regulatory guidance and requirements, especially those found in the Medicare Program Integrity Manual Chapter 13, to include all the following:o Development and maintenance of new LCDs and Articles, including thorough review, analysis, and summary of the following: claims data, pertinent CMS instruction, available evidence, including but not limited to published medical literature, discussion with Contractor Advisory Committee (CAC) members, subject matters experts (SMEs), Medicare providers etc., correct coding and billing requirementso Review of Reconsideration Requests and completion of appropriate resulting LCD revisions o Annual and other mandatory updates (e.g., diagnosis and procedure codes, Change Requests, etc.)o Development and maintenance of accessible electronic LCD and Article files o Participation in the formal, external Open Meetings and CAC meetings including creation and presentation of information specific to assigned LCDso Review and revision of departmental procedures related to LCD development and revisions. Subject Matter Expert (SME): (20%)* Serves as point of contact for internal operations regarding medical coverage and coding questions.* Collaborates with edit team to ensure appropriate edits are created in keeping with the LCD instruction.* Serves as SME for assigned LCDs and Articles and interfaces with technical, professional, and clinical personnel; routinely interacting with all levels of staff in the company, including the Executive Medical Directors, as well as other senior leaders.* Attends regularly scheduled internal meetings to ensure adequate information sharing and education as appropriate throughout the company regarding LCDs and Articles. * Accountable for regular and ongoing communication with external customers, including but not limited to, CMS, local and national medical societies/associations, stakeholders, other professional organizations, and Medicare providers, to ensure adequate information sharing and education regarding LCDs and Articles.* Routinely and proactively collaborates with team members including the CMDs, senior leadership, and operational leads as necessary to identify and implement improvements related to the policy development process.
Performs other duties as the supervisor may, from time to time, deem necessary.
REQUIRED QUALIFICATIONS* High School Diploma or GED * 3 years' related work experience; this includes 2 years of Medicare experience and 1 year of health insurance coding (e.g., ICD-10, CPT/HCPCS) experience* Proficient in research of the CMS Internet-Only manual (IOM) and national and local coverage decisions* Proficient in MS Office applications and Internet research * Comprehensive knowledge of medical, surgical and diagnostic procedures and terminology* Excellent written and oral communication skills* Ability to communicate with confidence with other medical professionals, Medical Societies, Medicare providers, CMS and Contractor Advisory Committee (CAC) members * Professional demeanor and positive approach to work* Excellent planning, organizing, time and work management skills* Ability to travel
CERTIFICATIONS, LICENSES, REGISTRATIONS* Valid unrestricted Registered Nurse (RN) license
PREFERRED QUALIFICATIONS* Bachelor's degree in Nursing * 5 or more years of clinical experience as a Registered Nurse* 3 or more years of Medicare experience * 3 or more years of experience in Health or Business Administration* 3 or more years of health insurance experience in operations, claims review, case review, education, and/or medical and payment policy * 3 or more years of health insurance coding (e.g. ICD-10-CM, CPT/HCPCS)* Certified Professional Coder (CPC) certification/credential
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