Sr. Medical Policy Developer

The Role

The Sr. Medical Policy Developer reports to the leader of Medical Policy Administration and is primarily responsible for creating and revising custom medical policies using InterQual as well as creating policies not using InterQual. This includes working as an individual contributor and collaborating with other departments, external stakeholders, and team members to support Medical Policy Administration. This role requires proficiency in clinical writing, critical thinking skills and coding skills.

This position is eligible for the Flex persona. Local candidates are required to work from the Hingham office 2X per month.

Key Responsibilities

• Utilizes clinical knowledge to create custom questionnaires based on medical policy guidelines and input into InterQual.
• Revises and maintains customized medical policies in InterQual. This includes but not limited to criteria and code changes.
• Appropriately applies procedural and diagnostic coding (CPT, HCPCS, and ICD) to policy criteria with an understanding of the impact on policy enforcement.
• Actively participates in testing and validation of customized medical policies in InterQual.
• Works with system users to ensure consistent application and implementation of policies.
• Serves as a clinical consultant for the annual InterQual criteria and identifies any changes. Presents changes to Medical Directors for approval as needed.
• Facilitates meetings with external physicians as needed.
• Attends the Association monthly Medical Policy Group meetings and keeps the team informed of policy changes by documenting minutes and tracking monthly changes.
• Creates monthly Medical Policy Announcement table.
• Represents Medical Policy Administration in various divisional and interdepartmental meetings.
• Responsible for updating/creating medical policies not in InterQual as needed.
• Responds to internal and external clinical mailbox inquiries from local physicians and clinical directors regarding policy content and rationales, as well as analysis and responses for industry representatives seeking coverage for advancing medical technologies as needed.
• Research clinical content (papers, PubMed, etc), document findings and provide recommendations on research outcome as needed.
• Conducts comparative market analysis for coverage positions, analyzing utilization, volume, and data trends as needed.
• Other duties as assigned.

Qualifications

• RN or PA-C required
• CPC required or desire to become certified
• BSN preferred
• Proficient in medical writing/clinical documentation
• Experience using InterQual preferred
• Strong Computer Skills. Proficient with Windows applications.
• Strong planning, organization and time management including the ability to meet deadlines, problem solve, and manage multiple competing priorities
• Demonstrated critical thinking and analytical skills
• Ability to work effectively individually and as part of a collaborative team.

#LI-Remote

High school degree or equivalent required unless otherwise noted above

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that theconfidence gapandimposter syndromecan prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.