Medical Policy Implementation Analyst
Remote within WA, OR, ID, or UT
The Medical Policy Implementation Analyst identifies, recommends and publishes clinical policy criteria for all lines of business. Organizes and maintains policies so they are accessible to internal and external customers. Consults with Medical Directors and other internal staff on policy development and implementation as well as system application.
- Effectively drafts, interprets and applies medical policies and assists in the workload distribution of the medical policy team. Present policy criteria recommendations to Medical Directors and other internal staff for approval.
- Tracks patterns in utilization and appeals to inform policy criteria changes and new policies.
- Appropriately applies procedural and diagnostic coding (CPT, HCPCS, and ICD) to policy criteria with an understanding of the impact on policy implementation.
- Implements, maintains, and publishes on the web a library of clinical criteria that is accessible to internal and external customers.
- Works with system users and databases to ensure consistent application and implementation of policies.
- Develops and maintains related department procedures.
- Ability to manage project tasks, set objectives, goals, and develop schedules while meeting deadlines and documentation requirements for accreditation standards with minimal supervision
Normally to be proficient in the competencies listed above
- Demonstrated knowledge of the following: anatomy and physiology/disease processes; medical terminology, medical and surgical procedures.
- Familiarity with CPT, ICD and HCPCS coding for medical technologies, procedures, and services.
- Familiarity with utilization review and clinical claim review process.
- Demonstrated knowledge of coverage policies, policy application hierarchy and search methodologies. Knowledge of CMS Medicare coverage guidelines and compliance rules desirable.
- Demonstrated analytical ability to identify problems, develop solutions and implement a chosen course of action with internal and external medical professionals and other experts.
- General computer skills (including use of Microsoft Office, Outlook) and various Web-based internet applications.
- Strong organization skills, and an independent worker.
Medical Policy Implementation Analyst would have a Bachelor's degree in health science related field and 3 years of experience in review and interpretation of medical policy and directives (may include utilization management, payment review, appeals, etc.) or equivalent combination of education and experience.Required Licenses, Certifications, Registration, Etc.
Certified Professional Coder (CPC) preferred
Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We've been here for members for 100 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association.
If you're seeking a career that affects change in the health care system, consider joining our team at Cambia Health Solutions. We advocate for transforming the health care system by making health care more affordable and accessible, increasing consumers' engagement in their health care decisions, and offering a diverse range of products and services that promote the health and well-being of our members. Cambia's portfolio of companies spans health care information technology and software development; retail health care; health insurance plans that carry the Blue Cross and Blue Shield brands; pharmacy benefit management; life, disability, dental, vision and other lines of protection; alternative solutions to health care access and free-standing health and wellness solutions.
This position includes 401(k), healthcare, paid time off, paid holidays, and more. For more information, please visit www.cambiahealth.com/careers/total-rewards
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check are required.
If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com