Consultant, Medical Coverage Policy

HealthPartners is hiring a Consultant, Medical Coverage Policy. The Consultant is responsible for the development, maintenance, review, and implementation of medical policies/criteria which support clinical decision-making coverage for services that are rooted in scientific evidence, proven to positively impact healthcare outcomes. This position monitors, reviews and analyzes medical literature for current, new and emerging technology. This position also manages administrative criteria which supplement benefits and third-party resources. The Consultant is a collaborative position that works with many cross functional departments including Claims, Utilization Management (UM), Medical Directors, Contracts and Benefits, Member Services/Appeals, and Government Programs to support policy changes. The position serves as a content expert related to medical coverage policies and offers continued support to internal and external partners.

MINIMUM QUALIFICATIONS:

• Education, Experience or Equivalent Combination:
  
  
  
  • Bachelor's degree in nursing
  • RN with 3-5 years of medical policy experience.
  • Five or more years of healthcare experience, with expertise in the areas of scientific literature research and review, medical guideline development, or coverage policy development
  • Demonstrated health plan implementation experience or knowledge and experience working with health plan operations
  
  
• Licensure/ Registration/ Certification:
  
  
  
  • Current Minnesota RN license
  
  
• Knowledge, Skills, and Abilities:
  
  
  
  • Technically competent with expertise in creating Microsoft Word and Excel documents
  • Ability to continuously learn new technical skills, competencies, systems or programs
  • Ability to prioritize multiple competing complex tasks, meet deadlines and manage multiple assignments in various stages of development and implementation
  • Ability to plan and organize tasks to complete a project, facilitate collaboration with others and create and manage documentation
  • Ability to work autonomously, deal with ambiguity and respond positively to change
  • Demonstrated effective interpersonal, verbal, and written communication skills
  • Experienced with conducting review and analysis of clinical literature and using critical thinking skills to summarize and synthesize evidence-based findings, complex clinical information and technical information.
  • Displays initiative in identifying problems and outlining possible solutions for review with leaders.
  • Able to identify, understand, and anticipate implications of coverage positions
  
  

PREFERRED QUALIFICATIONS:

• Education, Experience or Equivalent Combination:
  
  
  
  • Expertise in medical coding (HCPCS, CPT, ICD-10) related to claims billing, claims processing, and claims implementation strategies
  • Experience in requesting and understanding health plan cost and utilization data
  • Demonstrated skill in collaboration and group facilitation
  • Experience in health plan Utilization Management.
  
  
• Licensure/ Registration/ Certification:
  
  
  
  • Current or previous certification in medical coding
  
  
• Knowledge, Skills, and Abilities:
  
  
  
  • Expertise in PowerPoint, and Visio
  • Knowledge of, and expertise in Medicare.
  
  

ESSENTIAL DUTIES:

1. (15%) Research, identify, analyze and evaluate evidence based scientific literature and use critical thinking skills to summarize and synthesize evidence-based findings, complex clinical information and technical information which affect medical coverage policies and benefits.
2. (15%) Develops professional documents which summarize scientific literature and administrative research as support for health plan coverage positions. Delivers verbal and written presentations.
3. (10%) Research and interpret benefit coverage across all health plan products including Commercial, Medicare, Medicaid and employer groups. Identifies and applies health plan benefit variances in coverage from product to product and state to state. Researches and complies with applicable laws, CMS requirements, regulatory and accreditation standards to support departmental initiatives and incorporate into coverage policy work.
4. (10%) Reviews and summarizes informatics and claims reports to understand volume, costs and coding implications to support policy implementation and maintenance.
5. (10%) Develops and revises coverage criteria policies including evidence-based, administrative policies and benefit supplemented policies, which support medical directors and leaders in designing medical coverage policy strategy.
6. (15%) Accountable for successful implementation of all assigned work. Collaborates with other departments as needed; prepares implementation plans; identifies and implements claims edits related to coverage policies; facilitates completion and resolves critical implementation issues.
7. (10%) Communicates coverage policy interpretation, explanation and rationale for coverage positions and implementation approach to providers, members, outside vendors, employer groups and internal departments.
8. (15%) Provides staff support for various committees, administrative work, evolving departmental work, and other duties as assigned.