Medical/Clinical Policy Reimbursement Writer

Medical/Clinical & Reimbursement Policy Writer

Job Summary: The Medical/Clinical & Reimbursement Policy Writer researches and develops moderate to complex medical, administrative and reimbursement provider policies; ensures adherence to company, state, and federal guidelines.

Essential Functions:

• Support the operational processes of the Clinical Provider Policy Governance Committee (CPGC)
• Ensure all new and existing configuration rules are incorporated into the clinical policies
• Responsible for the tactical activities related to the support of CareSource's reimbursement policies
• Provide medical, administrative and reimbursement policies policy deliverables for all lines of business
• Participate in department initiatives and projects
• Ensure all reimbursement policies are compliant with relevant regulations and are consistent across all lines of business
• Assist, identify and define Claims Ops solutions to meet regulatory requirements
• Coordinate with subject matter experts to develop policy on issues that impact CareSource from medical/clinical, and reimbursement policies policy perspectives
• Support cross functional teams with responses and restitution projects
• Remediate gaps in existing processes related to medical, administrative and reimbursement provider policies that do not meet regulatory requirements
• Work with business product owners, government relations, and compliance leads to monitor legislative and regulatory activities for potential impact on existing or proposed policies
• Collaborate with interdisciplinary team members to achieve team goals
• Monitor status reports to ensure effective workflow and timely development of medical, behavioral health, administrative and reimbursement policies

Perform any other job duties as requested

Education and Experience:

• Bachelor's Degree or equivalent years of relevant work experience is required
• Technical writing experience is required, preferably healthcare policy or related
• Previous managed care experience to include experience with medical coding, claims payment, and/or retrospective claims reviews is preferred
• Healthcare experience strongly preferred

Competencies, Knowledge and Skills:

• Ability to develop detailed data specifications
• Knowledge of Clinical Editing applications
• Understanding of Healthcare Economics
• Knowledge of NCQA policy timely requirements
• Strong understanding of healthcare reimbursement practices
• Ability to translate ideas into clear and concise written communication
• 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
• Strong presentation and decision-making skills
• Excellent organization and tracking skills
• Good problem-solving skills
• Ability to interface with employees at all levels
• Ability to handle multiple priorities/projects simultaneously

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 or stand for extended periods of time
• Virtual office opportunity, with occasional travel to main office

Compensation Range: $70,800.00 - $113,200.00 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