To be fully engaged in providing No Harm / Quality, Customer Experience, and Stewardship by developing and maintaining Medical Policies that define medical necessity under Health First benefit plans. The position creates value by maximizing operational effectiveness in the Utilization Management area, ensuring consistent and appropriate decision-making and minimizing legal risk. Medical Policy Administration involves the analysis of health data, clinical research, cost-effectiveness, and health policy, with the development of professional written Policies and other communication tools. Generally works under specific deadlines and frequently handles multiple complex projects, operating with minimal supervision.
Adhering to and enforcing all corporate safety initiatives
Overseeing the development, implementation and maintenance of operational Policies and Procedures
Ensuring that Medical Policies consider patient safety
Developing high-quality Medical Policies and associated documents based on evidence, taking into account clinical research, data analysis, best-practices, the synthesis of available information. Presents research and recommendations to internal teams and Physician Advisory Committee.
Ensuring that processes related to Medical Policies comply with state and federal regulations and quality accreditation standards
Implementing Medical Policies in accordance with product line contract requirements, working with the system configuration team as needed.
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
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
Bachelor’s degree or equivalent training in health care or Business Administration. A degree in nursing is preferred. Master’s degree a plus.
8+ years of health care/medical industry experience at a professional/management level
Advanced understanding of medical terminology
Thorough knowledge of relationships between medical policy, benefits, provider contracts, and claim processing
In-depth knowledge of CMS guidelines related to benefits, coverage determinations, billing and reimbursement.
Professional writing and editing experience, with document formatting skills
Strong command of the English language, including basic grammar and writing principles
Strong decision-making ability, interpersonal skills and communication skills
Job : Medical Management Organization : Health First Health Plans, Inc Primary Location : United States-Florida - Brevard County-Rockledge Schedule : Full-time Shift Times : 8:30 am — 5:00 pm Job Level : Associate
Internal Number: 033381
About Health First
Health First is Central Florida's only fully integrated health system. With a mission to positively change the health and wellness of the communities we serve, Health First offers the latest technological advances and quality care at our four hospitals and through our many Outpatient & Wellness Services, as well as the area's only Trauma and Heart Centers. Health First also offers multiple commercial and Medicare health plans, the largest multi-specialty physician group in Brevard County, and four fitness centers to help members of our community stay healthy.