Medical Policy Specialist - Research & Coverage Guidelines

Job Title: Medical Policy Specialist - Research & Coverage Guidelines

Location: Remote (AZ preferred)

Duration: 6 Months (Temp to Hire)

Position Type: Full Time

Key Responsibilities:

* Perform medical technology research related to coverage guidelines and new technologies.

* Develop, revise, and maintain medical coverage guidelines and criteria.

* Evaluate and summarize research findings for Medical Director Staff and Medical Policy Panel.

* Participate in Medical Policy Panel discussions and support Clinical Coding Governance Committee (CCGC) activities.

* Maintain knowledge of Association Medical Policy Reference Manual, MCG Care Guidelines, Change Healthcare InterQual, and eviCore criteria.

* Facilitate and summarize external consultant reviews regarding coverage guidelines or new technologies.

* Communicate medical policy information to internal stakeholders and healthcare providers.

* Perform code reviews and provide recommendations for benefit programming integration.

* Support training, development, and mentorship of Level I staff.

* Ensure compliance with State, Federal, client, and accreditation requirements.

Required Experience:

* 2+ years of experience in a clinical field, health insurance, or healthcare-related field.

* 1+ year of experience in medical policy and technology research.

* Associate's Degree in general field of study or Post High School Nursing Diploma or Certification (LPN only) from an approved program (Applies to All Levels)

* Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN, LPN, LPT, LBSW, LMSW, or LCSW. (Applies to All Levels)

* Experience researching, developing, revising, and reviewing medical policies.

* Experience working with coverage guidelines and clinical criteria.

Required Skills:

* Medical policy research and development.

* Technical research, analysis, and policy writing.

* MCG Care Guidelines and/or Change Healthcare InterQual.

* eviCore criteria.

* Coverage guideline development and revision.

* Clinical coding review.

* Collaboration with Medical Directors, physicians, nurses, and policy committees.

Licensure/Education:

* Active, unrestricted Arizona healthcare license (RN, LPN, LPT, LBSW, LMSW, or LCSW).

* Associate's Degree or Post High School Nursing Diploma/Certification (LPN).