Company :Highmark HealthJob Description : 

JOB SUMMARY

Highmark follows Medicare coverage guidelines and regularly develops and/or updates the Medicare Advantage policy to comply with changes in Centers or Medicare & Medicaid Services. We encourage physicians and other healthcare professionals to keep current with any CMS policy changes and/or billing requirements by referring to the CMS or their local carrier (MAC) website regularly. Medicare Advantage Policy Guidelines are developed as needed based on CMS documentation for medical services and their specific covered/noncovered indications. Medicare Advantage policies are written for Pennsylvania, Delaware, West Virginia, and New York. 

The incumbent for this position is responsible for the research and development of Medicare Advantage Medical policies utilizing CMS Documentation sources including: National (CMS) and local coverage determination (MAC), Medicare learning network (MLN), Transmittals, Claims Processing Manual, Benefit Policy Manual.            
 

ESSENTIAL RESPONSIBILITIES

Conduct full-cycle ownership of the Medicare Advantage policy including new development, revision, and maintenance for assigned Medicare Advantage policies. Responsible for the research, analysis, development, maintenance, coordination, and documentation of Highmark’s Medicare Advantage medical policy.   Interpret clinical, reimbursement and benefit guidelines from CMS and compare them to existing policies, to determine whether changes are required.  If changes are required, update policies and revise accordingly.  These evaluations require a detailed analysis and interpretation of various forms of CMS documentation.Accountable for coordinating and ensuring that the appropriate system changes are implemented in accordance with policy development and revisions for proper claims adjudication. Coordinating policy issues pertaining to the Medicare Advantage policy with internal or external customers.  Responsible for all coordination necessary related to policy maintenance and implementation.   Monitor incoming notifications from CMS and conduct external research as appropriate. Research inquiries and manage policy decisions and/or recommendations to management. Respond to inquiries from both internal and external sources. Must be able to explain and support the rationale for the policy to accurately respond to inquiries.  Lead or assist projects that have an impact on Medical Policy.Review Medicare Advantage medical policies for quality assuranceOther duties as assigned or requested.

EDUCATION

Required

Bachelor's Degree in Business Administration/Management, Communications , English, Health Administration or related field

Substitutions

6 years of health care experience can be substituted in lieu of education.

Preferred

None

EXPERIENCE

Required

3 years in the Healthcare Industry

Preferred

1 year with medical policy development1 year with claims processing1 year of researching and interpreting medical, reimbursement and benefit policy1 year with medical policy1 year in medical coding

LICENSES OR CERTIFICATIONS

Required

None

Preferred

Certified Professional Code (CPC)

SKILLS

Excellent verbal & written communication skills Excellent time management skills Prioritization skillsProblem solving and Decision making skills Critical/logic thinking skillsAnalytical and detail oriented Team player 

Language Requirement (other than English)

None

Travel Required

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Rarely

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required 

Yes

Lifting: up to 10 pounds

Occasionally

Lifting: 10 to 25 pounds

Rarely

Lifting: 25 to 50 pounds

Rarely

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. 

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

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