• This position is a full time remote, work from home opportunity. You must reside within the state of Florida.

POSITION SUMMARY\:

To be fully engaged in providing No Harm / Quality, Customer Experience, and Stewardship by applying broad medical, regulatory, and benefits administration knowledge to research, write, edit and implement Medical Policies. The position creates value by maximizing operational effectiveness in the Utilization Management, Claims and Appeals processes, ensuring consistent and appropriate decision-making and minimizing legal risk. The Medical Policy Administrator focuses on clinical decision analysis, cost-effectiveness and health policy analysis to develop and maintain a Medical Policy library for the Health Plan. Medical Policies will be developed by applying decision analysis, literature synthesis, medical informatics, and expert benefit interpretation. Medical Policies will combine information extracted from technology assessments, clinical guidelines, health outcome analyses, expert panels and conferences, as well as from pertinent clinical informatics and clinical decision support documentation. Additional responsibilities include maintenance of the Prior Authorization List with applicable health care coding references, and active participation in a variety of operational workgroups. Generally works under specific deadlines and frequently handles multiple complex projects, operating with minimal supervision.

PRIMARY ACCOUNTABILITIES\:

Quality/No Harm\:

• Adhere to and enforce all corporate safety initiatives
• Ensures all Medical Policy content meets patient safety guidelines
• Provides professional and analytical support focusing on the analysis, development, maintenance, and evaluation of HFHP Medical Policies for all product lines
• Writes, proofs and edits Medical Policies including maintaining a detailed history of research, coverage determinations and recommendations. Makes high level presentations on research and recommendations to internal teams, and to the Physician Advisory Committee.
• Researches and identifies best practices and evidence based research studies in support of the development and maintenance of state of the art Medical Policies
• Prepares templates for Medical Policy documents and determines format for best presentation of data
• Ensures document content adheres to appropriate accreditation standards and regulatory guidelines
• Provides professional/analytical support with policy interpretation to applicable product lines, including implementation, operation and contract compliance (e.g. Medicare program)
• Oversees the development and maintenance of all departmental Policies and Procedures related to Medical Policy administration
• Consults with applicable industry resources, regulatory authorities and health plan administrators to facilitate the development and maintenance of applicable Medical Policies
• Ensures professional product is comprehensive and accurately reflects local medical practice
• Monitors and reports on industry developments which may impact applicable medical services offerings including legislative/legal developments at the local, state and federal level
• Maintaining and regularly updating the Prior Authorization List based on input from the Utilization Management Workgroup and clinical leadership
• Interacts with internal teams as needed to ensure that medical policies accurately address current workflow processes and operations
• Interacts extensively with medical directors and health plan clinicians regarding Medical Policies
• Utilizes health plan resources in determining accurate diagnosis and procedure coding for appropriate policy development
• Leads the Code Management Team in its review of new and existing procedure and diagnosis codes providing recommendations regarding coding that affects benefits, payment, and other operational processes.
• For the duration of the ICD-10 implementation project, acts as HFHP’s business lead, conducting necessary financial and operational impact assessments, developing a project schedule and associated tasks, and developing and executing operational and communication strategies.
• Implements regulatory requirements related to preventive benefits, including extensive knowledge of related state and federal laws and specific guidelines, as well as overseeing code-level implementation of preventive services.

Customer Experience\:

• Develops and maintains effective systems to communicate information related to Medical Policies to internal and external customers

Stewardship\:

• Develops Medical Policies that support utilization management and appeal activities that are designed to ensure appropriate use of medical services

QUALIFICATIONS REQUIRED\:

• Bachelor’s degree or equivalent training in health or Business Administration is required. A degree in nursing is preferred. Masters degree a plus.
• Professional writing and editing experience required. Document/template formatting skills required as well.
• 8+ years of health care/medical industry experience required at a professional/management level.
• Thorough knowledge of relationships between medical policy, member benefits, provider contracts, and claims operations.
• In-depth knowledge of diagnosis and procedure codes, reimbursement methodologies, medical terminology, and HFHP and CMS guidelines. Professional coding certification preferred.
• Strong command of the English language, including basic grammar and writing principles, and knowledge of medical terminology.
• Strong decision-making ability, interpersonal skills and communication skills.
• Professional coding certification preferred

PHYSICAL DEMANDS\:

• Ability to use a computer for extended periods of time, including sitting, typing, and viewing text on a computer monitor

MENTAL DEMANDS\:

• Maintaining a high level of motivation, initiative and accountability
• Staying organized and effectively prioritizing work and managing time
• Handling multiple tasks, often within limited time frames
• Working in a fast-paced and often stressful environment.
• Handling conflict in a productive manner
• Working effectively with all levels of employees and management

COMPETENCY ASSESSMENT/SKILLS CHECKLIST\:

• Advanced verbal and written communication skills, with proven ability to communicate professionally
• Motivation, initiative and accountability
• Data collection and quantitative decision-making skills
• Analytic and creative problem-solving skills
• Must be highly proficient in the use of Microsoft Office suite (especially Microsoft Word, Excel and PowerPoint)
• Organization and time management, with the ability manage multiple responsibilities effectively