Job Title: Medical Policy Specialist – Research & Coverage Guidelines
Location: Phoenix, AZ (Hybrid, 1 day required on site - Wednesdays)
Position Type: Full Time

Job Description

• Perform medical technology research related to coverage guidelines and new technology and provide evaluation and summarization to Medical Director Staff and/or Medical Policy Panel. 
• Perform medical technology research as requested by other areas of the organization through the Medical Policy Referral Form.
• Develop and revise coverage guidelines and criteria as requested by management, Medical Director staff, or Medical Policy Panel.
• Communicate medical policy information in protocol format to all areas of the organization requiring this information.
• Participate as a contributing member on the Medical Policy Panel, providing medical policy issues for discussion, and as required, on the Clinical Coding Governance Committee (CCGC).
• Maintain a thorough knowledge of all medical coverage guidelines and other policies, such as Medical Policy Reference Manuals, MCG care guidelines, Change Healthcare InterQual, and eviCore criteria.
• From the direction of management, Medical Director staff, or Medical Policy Panel, facilitate external consultant reviews concerning a coverage guideline or new technology. Responsible for initiating the consultation, providing a summary of the external review to the requestor, and coordinating appropriate reimbursement for the consultant’s review.
• Communicate medical policy information in protocol format to healthcare providers upon request.
• With moderate assistance and review by management, perform basic-level code review.
• Meet quality, quantity, and timeliness standards to achieve individual and department performance goals as defined within department guidelines and required by State, Federal, and other accrediting organizations.
• Maintain all standards in consideration of State, Federal, organizational, and other accreditation requirements.
• Assist management with the implementation of daily operations related to guideline development and revisions, staff supervision, and coaching to help each staff member achieve personal, professional, and departmental goals.
• Assist management with coordinating all aspects of Medical Policy Panel and Medical Director meetings, including preparation, agenda development, and meeting minutes.
• Assist management with the completion of monthly, quarterly, and annual reporting.
• Assist management with coordinating all aspects of annual reviews of MCG, eviCore, and/or Change Healthcare InterQual criteria updates.
• Assist management with providing oversight to responsible staff for the monthly review of Medical Policy and Reference Manual updates.
• Assist management with providing initial training and instruction for both professional and technical staff and coordinating desk-level training for new team members.
• Responsible for the training, development, and support of Grade III staff under an established training program.
• Conduct and/or participate in internal committees that further organizational and departmental goals.
• Working independently, perform advanced code review with advanced knowledge and understanding of coverage guideline development and revisions, providing recommendations to the Clinical Coding Governance Committee (CCGC) for integration into benefit programming.

 
 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $ 35.00/Hourly.