Job Description

Develops medical/dental and reimbursement policies for coverage guidance of new drugs, technology, medical/dental procedures and clinical codes. Initiates the process for internal and external review of corporate medical/dental and reimbursement policies to meet all compliance regulations. Responds to internal and external inquiries regarding policies, benefit application and reimbursement strategies. Represents the Healthcare Division as clinical or coding advisors. Analyzes clinical/dental service codes that are applicable to medical/dental and reimbursement policy, including but not limited to: research of newly developed codes, review of claims data, and assessment of system configuration.

What You'll Do

• Initiates and coordinates the internal and external reviews of medical/dental and reimbursement policies as required by regulatory agencies.
• Identifies and initiates the medical/dental policy development process for the modification or creation of policies to address Plan needs as they occur.
• Gathers appropriate resource information necessary for policy/technology assessment including, but not limited to, scientific literature searches, approval status by appropriate governmental regulatory bodies, practice guidelines, relative position statements, and materials from the Blue Cross and Blue Shield Association Technology Evaluation Center. Analyzes, makes recommendations, and prepares initial drafts of policies.
• Oversees the ongoing maintenance of the internal and external medical policy websites and the on-line medical policy manual to ensure data is current and accurate.
• Identifies the need for, and drafts, public policy notifications to providers and members, communicating new medical/dental policy guidelines or impactful policy changes
• Serves as the Subject Matter Expert for applicable coding and policy issues that arise both internally and externally.
• Serves as a resource to internal stakeholders (i.e. sales and marketing, compliance) for medical/dental integrated benefit design.

What You'll Bring

• RN, LPN or Dental Assistant, based on area of focus
• 3+ years of experience in related field
• AAPC Certified Professional Coder

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.

*Based on annual corporate goal achievement and individual performance.

$81,068.00 - $129,708.00

Skills

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