Medical/Clinical & Reimbursement Policy Writer III
Job Summary:
The Medical/Clinical & Reimbursement Policy Writer III researches and develops moderate to complex medical and behavioral health, administrative and reimbursement provider policies; ensures adherence to company, state, and federal guidelines.
Essential Functions:
• Ensure all new and existing configuration rules are incorporated into policies
• Responsible for the tactical activities related to the support of CareSource’s reimbursement policies
• Perform as a SME regarding reimbursement policies
• Provide medical and behavioral health, administrative and reimbursement policies policy deliverables for Medicare, Medicaid, MyCare, D-SNP, Passe, Marketplace products and other markets as business needs change
• Partner with functional area leaders and SMEs to determine impact and solutions
• Assist, Identify and define Claims Ops solutions to meet regulatory requirements
• Support cross functional teams with responses and restitution projects
• Remediate gaps in existing processes related to medical and behavioral health, administrative and reimbursement provider policies that do not meet regulatory requirements
• Support the operational processes of the Clinical Provider Policy Governance Committee (CPGC)
• Monitor status reports to ensure effective workflow and timely development of medical, behavioral health, administrative and reimbursement policies
• Contributes and provides input to the development of operational area goals.
• Able to work independently on tasks that are typically are not routine and applies discretion within established operational boundaries and procedures.
• May provide informal coaching and leadership to team.
• Manages projects and key deliverables for the team.
• May provide leadership coverage in leadership absence
• Availability outside of normal business hours, if necessary
• Assist/support policy team when needed
• Perform any other job duties as requested
Education and Experience:
• Bachelor’s degree or equivalent years of relevant work experience is required
• Advanced degree or equivalent education/degree in life sciences/healthcare is preferred
• Minimum of three (3) years of technical writing experience required; healthcare policy background preferred
• Previous managed care experience to include experience with or knowledge of medical coding, claims payment, and/or retrospective claims reviews is preferred
• Healthcare experience strongly preferred
Competencies, Knowledge and Skills:
• Knowledge of Clinical Editing applications
• Ability to interpret complex clinical information and apply to policy development
• Excellent verbal and written communications skills
• Presentation and decision-making skills
• Excellent organization and tracking skills
• Good problem-solving skills
• Strong understanding of healthcare reimbursement practices
• Computer skills/proficiency level with Microsoft Word, Excel, search engines, and bibliographic software
• Knowledge of medical terminology and claims payment policies
• Advanced analytical skills, with the ability to interpret and synthesize complex healthcare literature
• Ability to interpret complex clinical information and apply to policy development
• Excellent verbal and written communications skills
• Ability to interface with employees at all levels
• Ability to handle multiple priorities/projects simultaneously
• Ability to manage competing priorities
• Maintain composure under stressful situations
Licensure and Certification:
• RN or equivalent clinical licensure preferred, or in lieu of licensure: 2 years Clinical /Medical policy writing experience or equivalent Policy/Healthcare experience
• CPC, CCS, COC, CIC Preferred
Working Conditions:
• General office environment; may be required to sit/stand for long periods of time
• Virtual office opportunity, with occasional travel to main office
Compensation Range:
$83,000.00 - $132,800.00
CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary
Organization Level Competencies
• Fostering a Collaborative Workplace Culture
• Cultivate Partnerships
• Develop Self and Others
• Drive Execution
• Influence Others
• Pursue Personal Excellence
• Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
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The Medical/Clinical & Reimbursement Policy Writer III researches and develops moderate to complex medical and behavioral health, administrative and reimbursement provider policies; ensures adherence to company, state, and federal guidelines.
Essential Functions:
• Ensure all new and existing configuration rules are incorporated into policies
• Responsible for the tactical activities related to the support of CareSource’s reimbursement policies
• Perform as a SME regarding reimbursement policies
• Provide medical and behavioral health, administrative and reimbursement policies policy deliverables for Medicare, Medicaid, MyCare, D-SNP, Passe, Marketplace products and other markets as business needs change
• Partner with functional area leaders and SMEs to determine impact and solutions
• Assist, Identify and define Claims Ops solutions to meet regulatory requirements
• Support cross functional teams with responses and restitution projects
• Remediate gaps in existing processes related to medical and behavioral health, administrative and reimbursement provider policies that do not meet regulatory requirements
• Support the operational processes of the Clinical Provider Policy Governance Committee (CPGC)
• Monitor status reports to ensure effective workflow and timely development of medical, behavioral health, administrative and reimbursement policies
• Contributes and provides input to the development of operational area goals.
• Able to work independently on tasks that are typically are not routine and applies discretion within established operational boundaries and procedures.
• May provide informal coaching and leadership to team.
• Manages projects and key deliverables for the team.
• May provide leadership coverage in leadership absence
• Availability outside of normal business hours, if necessary
• Assist/support policy team when needed
• Perform any other job duties as requested
Education and Experience:
• Bachelor’s degree or equivalent years of relevant work experience is required
• Advanced degree or equivalent education/degree in life sciences/healthcare is preferred
• Minimum of three (3) years of technical writing experience required; healthcare policy background preferred
• Previous managed care experience to include experience with or knowledge of medical coding, claims payment, and/or retrospective claims reviews is preferred
• Healthcare experience strongly preferred
Competencies, Knowledge and Skills:
• Knowledge of Clinical Editing applications
• Ability to interpret complex clinical information and apply to policy development
• Excellent verbal and written communications skills
• Presentation and decision-making skills
• Excellent organization and tracking skills
• Good problem-solving skills
• Strong understanding of healthcare reimbursement practices
• Computer skills/proficiency level with Microsoft Word, Excel, search engines, and bibliographic software
• Knowledge of medical terminology and claims payment policies
• Advanced analytical skills, with the ability to interpret and synthesize complex healthcare literature
• Ability to interpret complex clinical information and apply to policy development
• Excellent verbal and written communications skills
• Ability to interface with employees at all levels
• Ability to handle multiple priorities/projects simultaneously
• Ability to manage competing priorities
• Maintain composure under stressful situations
Licensure and Certification:
• RN or equivalent clinical licensure preferred, or in lieu of licensure: 2 years Clinical /Medical policy writing experience or equivalent Policy/Healthcare experience
• CPC, CCS, COC, CIC Preferred
Working Conditions:
• General office environment; may be required to sit/stand for long periods of time
• Virtual office opportunity, with occasional travel to main office
Compensation Range:
$83,000.00 - $132,800.00
CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary
Organization Level Competencies
• Fostering a Collaborative Workplace Culture
• Cultivate Partnerships
• Develop Self and Others
• Drive Execution
• Influence Others
• Pursue Personal Excellence
• Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
#LI-JM1
Apply tot his job
Apply To this Job