Medical Policy Development Research Specialist -Registered Nurse
Blue Cross Blue Shield of Arizona is a local, independent Blue Cross Blue Shield Association and a not-for-profit health insurance company headquartered in Phoenix. Founded in 1939, the company has more than 1,800 dedicated employees throughout its Phoenix, Tucson, Chandler and Flagstaff offices. Providing health insurance products, services and networks to more than 1 million Arizonans, Blue Cross Blue Shield of Arizona offers various health plans for individuals, families, and small and large businesses. Blue Cross Blue Shield of Arizona also offers Medicare supplement plans to individuals over age 65.
Blue Cross Blue Shield of Arizona helps to fulfill its mission of improving the quality of life of Arizonans by delivering a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.
Perform medical technology research to support the Medical Director Staff and Medical Policy Panel with decisions to ensure that medical policies are consistent with the standards of accepted medical practice in the community.
- Perform medical technology research related to coverage guidelines and new technology and provide evaluation and summarization to Medical Director Staff and/or Medical Policy Panel
- Perform medical technology research as requested by other areas of BCBSAZ thru the Medical Policy Referral Form
- Develop and revise coverage guidelines and criteria as requested by management, Medical Director Staff or Medical Policy Panel
- Communicate medical policy information in protocol format to all areas of BCBSAZ requiring this information
- Participate as a contributing member on the Medical Policy Panel providing medical policy issues for discussion and on the Medical Coverage Benefit Integration Group (McBig)
- Maintain a thorough knowledge of all BCBSAZ medical coverage guidelines and other policies, such as BCBS Association Medical Policy Reference Manual and McKesson InterQual Criteria
- From the direction of management, Medical Director Staff or Medical Policy Panel, facilitate external consultant reviews concerning a coverage guideline or new technology.
- Responsible for initiating the consultation and providing a summarization concerning the external review to the requestor. Responsible for arrangements for appropriate reimbursement for the consultant’s review.
- Communicate medical policy information in protocol format to healthcare providers upon request
- With moderate assistance and review by management, perform basic level of code review
- Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations
- Maintain all standards in consideration of State, Federal, BCBSAZ and other accreditation requirements
- Working independently, recognizes necessity of an external consultant review concerning a coverage guideline or new technology, summarizing and reporting this information to management to facilitate the process as outlined for Level II
- With review by management, independently perform intermediate code review with knowledge and understanding of coverage guideline development/revisions with recommendations to McBig for integration into benefit programming
- Responsible for the training, development and support of grade level I staff under an established training program
- With review by management, independently perform advanced code review with advanced knowledge and understanding of coverage guideline development/revisions with recommendations to McBig for integration into benefit programming
- Working independently, initiate research from resource materials, e.g., clinical journals, periodicals, CMS (Medicare) guidelines and publications, BCBSA publications, other BCBS plans, and internet resources relating to technical, clinical and coverage guidelines, summarizing and reporting this information to management for further action
- Responsible for the training, development and support of grade level I and II staff under an established training program
- Assist manager with the implementation of daily operations with regard to guideline development and revisions, staff supervision, as well as necessary coaching to help each staff member reach personal, professional and department goals
- Assist manager with the coordination of all aspects of the Medical Policy Panel and Medical Director Meeting, including preparation, agenda and minutes.
- Assist manager with the completion of the monthly, quarterly and annual reporting to Director
- Assist manager with the coordination of all aspects of the annual review(s) of McKesson InterQual Criteria updates
- Assist manager with providing oversight to responsible staff for the monthly review of BCBS Association Medical Policy and Reference Manual (MPRM) updates
- Assist manager with providing the initial training and instruction for both professional and technical staff and designating the oversight of staff regarding training of new staff at the desk level of instruction/training
- Responsible for the training, development and support of grade level III staff under an established training program
- Conduct, and/or participate in internal committees that further the goals of BCBSAZ, the Health Services Division and the Medical Policy & Technology Department
- Working independently, perform advanced code review with advanced knowledge and understanding of coverage guideline development/revisions with recommendations to McBig for integration into benefit programming
- Each progressive level includes the ability to perform the essential functions of any lower levels.
- The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
- Perform all other duties as assigned.
BCBSAZ does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.
Skills / Requirements
- Required Work Experience
- 2 year(s) of experience in clinical field of practice, health insurance, or other health care related field (All Levels)
- 1 year(s) of experience in medical policy and technology research field (Applies to Level 2)
- 2 year(s) of experience in medical policy and technology research field (Applies to Level 3)
- Required Education
- Associate’s Degree in general field of study or Post High School Nursing Diploma
- Required Licenses
- Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional Registered Nurse (Applies to All Levels)
- Preferred Work Experience
- 3 year(s) of experience in clinical field of practice, health insurance, or other health care related field (All Levels)
- 1 year(s) of experience in claims retrospective review, utilization management, case management, appeals and grievances or quality review field (Applies to All Levels)
- Preferred Education
- Bachelor's Degree in Nursing or related field of study (Applies to All Levels)
- Preferred Licenses
- Active, current, and unrestricted State of Arizona (a state in the United States) license to practice as a Registered Nurse (Applies to All Levels)
- Required Job Skills
- Intermediate skill in use of office equipment, including copiers, fax machines, scanners and telephones
- Intermediate PC proficiency
- Intermediate Adobe PDF Standard proficiency
- Intermediate word processing, spreadsheet and presentation software proficiency (Applies to All Levels)
- Required Professional Competencies
- Maintain confidentiality and privacy
- Advanced clinical knowledge
- Practice interpersonal and active listening skills to achieve customer satisfaction
- Compose a variety of business correspondence
- Follow and accept instruction and direction
- Establish and maintain working relationships in a collaborative team environment
- Organizational skills with the ability to prioritize tasks and work with multiple priorities
- Independent and sound judgment with good problem solving skills (Applies to All Levels)