Health Plan Data and Medical Policy Clinician (Registered NurseRN)

Join Martins Point Health Care - an innovative not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force ofpeople caring for people Martins Point employees are on amission to transform our health care system while creating a healthier community. Martins Point employees enjoy an organizational culture of trust and respect where our values - taking care of ourselves and others continuous learning helping each other and having fun - are brought to life every day. Join us and find out for yourself why Martins Point has been certified as a Great Place to Work since 2015.

PRIMARY DUTIES AND RESPONSIBILITIES

Employees are expected to work consistently to demonstrate the mission vision and core values of the organization.

• Responsible for analyzing coverage payment and coding policies for current and emerging treatments (drugs devices and procedures) and informs organizational stakeholders of potential financial and/or operational impact in alignment with current industry evidence-based practice and regulatory standards.
• Examines and performs data management analyses including analyzing and extract data from the Enterprise Data Warehouse (EDW) and other sources
• Assists with ongoing development review edit and training of HMD standards and clinical guidelines in collaboration with HMD leadership as updates are obtained from regulatory entities through process improvement efforts and/or new plan products.
• Responsible for providing clinical/coding business knowledge to internal and external system applications and analytics team to inform system configuration data feed requirements and reporting specifications.
• Responsible for managing quarterly and yearly coding updates including research informing/ supporting Utilization Management leadership regarding policies/criteria and provides recommendations regarding authorization requirements and business initiatives.
• Responsible for UM system application business rules decision support tools and collaboration with internal systems application staff as well as external UM vendors to ensure they are supporting business objectives and regulatory requirements
• Assists with claims system benefit configuration and informs IT of coding/benefit updates
• Participates in technology and system planning and enhancement; recommends and tracks technology modifications that support the care disease and utilization management programs including UM application business rules.
• Serves as clinical department representative in Health Plan/Delivery System committees focus groups and other strategic interdepartmental initiatives as appropriate. Also serves as a subject matter expert resource to other analysts across the organization for clinical and coding knowledge. Takes a lead role in the tracking of progress and activities of key initiatives.
• Responsible for supporting SharePoint site for storing monitoring and maintenance of Health Management Department policies procedures and guidelines.
• Resource across the organization for escalated authorization requests claims disputes coding/coverage questions auditing and prepayment claims reviews.
• Maintains and is an expert user of third-party analytical tools and reporting platforms. Recommends tools and methodologies that can be deployed at the organizational level to departments and with external partners
• Leads Medical Policy Committee develops and updates evidence-based medical policies that are aligned with Industry standards and regulatory requirements
• Regularly evaluates Prior Auth List for code review and ROI support

POSITION QUALIFICATIONS

There are additional competencies linked to individual contributor provider and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position.

Education

• Associates s degree in nursing
• BSN preferred

Licensure/certification

• Current unrestricted Registered Nurse licensure in Maine.
• One or more of the following Certified Professional Coder Certifications (CPC CCS CCA CPMA)

Experience

• 5 years medical management experience in a managed care setting including Quality Management Case Management Disease Management Utilization Management and Population Health.
• Experience related to reporting and analysis of health care data ideally in the areas of managed care health care delivery code sets and/or reimbursement
• Experience with ICD10 CPT HCPCS and Revenue coding and payment systems for managed care.
• Experience with creating medical policies under the Medical Policy Committee
• Experience with Prior Auth list review addition and deletion of codes driven by evidence and utilization data
• Experience in creating reconciling summarizing and analyzing data with SQL knowledge preferred.

Knowledge

• Knowledge of health plan system application configuration/functionality and reporting
• Maintains working knowledge of DOD CMS NCQA CCMC State/Federal regulations and contractual obligations that affect HMD activities and departmental processes through collaboration with all related health plan departments.
• Maintains exemplary knowledge of each health plan line of business and impact(s) to HMD functions.
• Maintains exemplary knowledge of coding principles.
• Maintains knowledge of payment systems (IPPS OPPS PFS DRG APC DMEPOS ) and impact on reimbursement
• Maintains an understanding of health plan quality standards and measurements.
• Maintains knowledge of managed care computer systems features reporting claims system and claims processing practices including systems used throughout Martins Point (e.g. QNXT Athena Salesforce Microsoft Office iPro SharePoint Optum products Cognos Tableau SQL Server Management etc.).

Skills

• Excellent interpersonal verbal and written communication skills including team building and quality improvement skills.

Abilities

• Demonstrates an understanding of and alignment with Martins Point Values.
• Demonstrated ability to manage organize and prioritize workload and multiple competing demands in a timely accurate manner and function independently.
• Demonstrated knowledge of project management principles including ability to identify root causes and implement creative solutions with strong analytical and problem-solving skills.
• Ability to manage complex interdepartmental processes utilizing data to inform decision making and evaluate impacts. Aptitude for matching business requirements to potential software solutions.

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.

Martins Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process to perform essential job functions and/or to receive other benefits and privileges of employment please contact

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