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).

 
 
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.