Offer summary

Qualifications:

Bachelor’s Degree or equivalent relevant work experience is required., Technical writing experience, preferably in healthcare policy, is required., Previous managed care experience, including medical coding and claims payment, is preferred., Strong understanding of healthcare reimbursement practices and excellent communication skills are essential..

Key responsabilities:

Research and develop medical, administrative, and reimbursement provider policies.

Ensure compliance with company, state, and federal guidelines for reimbursement policies.

Coordinate with subject matter experts to address policy issues impacting CareSource.

Support cross-functional teams and monitor workflow for timely policy development.

Job description

Job Summary:

The Medical/Clinical & Reimbursement Policy Writer researches and develops moderate to complex medical, administrative and reimbursement provider policies; ensures adherence to company, state, and federal guidelines.

Essential Functions:

Support the operational processes of the Clinical Provider Policy Governance Committee (CPGC)
Ensure all new and existing configuration rules are incorporated into the clinical policies
Responsible for the tactical activities related to the support of CareSource’s reimbursement policies
Provide medical, administrative and reimbursement policies policy deliverables for all lines of business
Participate in department initiatives and projects
Ensure all reimbursement policies are compliant with relevant regulations and are consistent across all lines of business (duplicate with clinical policy writer)
Assist, Identify and define Claims Ops solutions to meet regulatory requirements
Coordinate with subject matter experts to develop policy on issues that impact CareSource from medical/clinical, and reimbursement policies policy perspectives
Support cross functional teams with responses and restitution projects
Remediate gaps in existing processes related to medical, administrative and reimbursement provider policies that do not meet regulatory requirements
Work with business product owners, government relations, and compliance leads to monitor legislative and regulatory activities for potential impact on existing or proposed policies
Collaborate with interdisciplinary team members to achieve team goals
Monitor status reports to ensure effective workflow and timely development of medical, behavioral health, administrative and reimbursement policies
Perform any other job duties as requested

Education and Experience:

Bachelor’s Degree or equivalent years of relevant work experience is required
Technical writing experience is required, preferably healthcare policy or related
Previous managed care experience to include experience with medical coding, claims payment, and/or retrospective claims reviews is preferred
Healthcare experience strongly preferred

Competencies, Knowledge and Skills:

Ability to develop detailed data specifications
Knowledge of Clinical Editing applications
Understanding of Healthcare Economics
Knowledge of NCQA policy timely requirements
Strong understanding of healthcare reimbursement practices
Ability to translate ideas into clear and concise written communication
Computer skills/proficiency level with Microsoft Word, Excel, search engines, and bibliographic software
Knowledge of medical terminology and claims payment policies
Advanced analytical skills, with the ability to interpret and synthesize complex healthcare literature
Ability to interpret complex clinical information and apply to policy development
Excellent verbal and written communications skills
Strong presentation and decision-making skills
Excellent organization and tracking skills
Good problem-solving skills
Ability to interface with employees at all levels
Ability to handle multiple priorities/projects simultaneously

Licensure and Certification:

RN or equivalent clinical licensure preferred, or in lieu of licensure: 2 years Clinical /Medical policy writing experience or equivalent Policy/Healthcare experience
CPC, CCS, COC, CIC Preferred

Working Conditions:

General office environment; may be required to sit or stand for extended periods of time

Virtual office opportunity, with occasional travel to main office

Compensation Range:

$70,800.00 - $113,200.00

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Salary

Organization Level Competencies