Manager, Medical Policy

Position Summary:

The Manager, Medical Policy reports to the Director of UM, and manages the personnel and work of the medical policy team, that researches, analyzes, develops and disseminates medical policies pertaining to medical and behavioral health services (e.g. procedures, DME, Part B drugs) ) and services addressing social determinants of health across all products and geographies in collaboration with key organizational stakeholders. He/she ensures that the policies which direct coverage of medical services are in compliance with regulatory, accreditation, and contractual requirements. The manager is a subject matter expert in the area of medical policy development and review and works collaboratively with the Sr. Medical Director of Medical Poliy and other company subject matter experts. The manager is responsible to translate industry standards into Medical policies and coverage of medical services for the organization's populations, develop recommendations to management for the coverage of ad-hoc medical services and to proactively monitor emerging healthcare technologies and products.

The medical policy manager facilitates the process for evaluating the effectiveness of company medical policies and prior authorization programs and supports the evaluation of payment policies. They ensure internal training materials and external provider documentation / communication related to medical policies is consistent with company policies, state, and federal guidelines.

Supervision Exercised:

• Yes

Essential Duties & Responsibilities:

• Responsible for staying abreast of all state and federal mandates, contract, regulatory and policy changes, and workflows impacting Medical Policies and related outcomes
• Coordinate with the Knowledge Hub Team on the annual review of all existing Medical Policies.
• Manage the medical policy team directly through specialized exempt and/or non-exempt employees; developingand managing budgets, schedules, and performance for the MP team
• Manage the annual review of MNG's owned by the medical policy team; updating themto align policy and practice with the needs of the population and ensuring compliance with all regulatory, contract and NCQA requirements.
• Together with the Director of UM and Sr. Medical Director of medical policy, manage the expansion the MP team to support the company's geographic and business expansions, including the centralization of all medical policy development,review and dissemination processes.
• Support internal business areas in the development, annual review and implementation of policies and guidelines currently owned by those areas; guide them through the updating them to ensure they align policy and practice with the needs of the population and compliance with all regulatory, contract and NCQA requirements. Provide education to staff regarding medical policy administration.
• Facilitate the annual evaluation of the effectiveness of company medical policies and prior authorization program.
• Support the payment policy and claims teams in the development of payment policies, and effectuation of medical policies and collaborate on claims projects ensuring they are relevant, compliant with regulatory, accreditation and contractual requirements and up to date on an as needed basis.
• Manage the development of new and review of existing medical necessity guidelines working closely with clinical staff by completing competitor, market and clinical research while aligning policy and practice with needs of the populations.
• Make recommendation for the acquisition of tools and resources to support the research needs of the Medical Policy staff
• Perform special projects as assigned by management
• Demonstrate knowledge and understanding of the laws, regulations, CCA's contracts and policies that pertain to CCA's business and conforms to these laws, regulations, and policies in carrying out the position duties and responsibilities.
• Primary representative of the medical policy team and serve as internal and external contact for inquiries related to Medical Policy, including medical necessity guidelines.
• Collaborate with other departments regarding provider manuals and internal training materials to ensure materials are consistent with policies and state and federal guidelines.
• Responsible to understand medical policy decision impact on Member, Provider, Regulator, and Contractual documentations/communications.
• Represent Medical Policy team at cross-functional and inter-discipllinary meetings and on organizational project teams, and frequently interact with subordinate Supervisors, and/or functional peer group managers.

Secondary responsibilities:

• Manage the processes which contribute to or support medical policy and central clinical operations work. These tasks may include:
  • Documenting or maintaining status reports, meeting minutes, issue/risk logs, interview guides, and project plans related to MP work
  • Generating insights and developing recommendations
  • Presenting updates, findings, and recommendations to clinical leadership, peers and associates at all levels as applicable for assigned projects
  • Actively contributing to team development and internal departmental improvements
  • Developing PowerPoint presentations, policy cases and policy summary briefs

Working Conditions:

• Standard office conditions-fully remote

Required Education:

• Bachelor Degree from an accredited college or university, in nursing or a health-related field preferred

Desired Education:

• Masters in Public Health, Healthcare Administration, or similar education and training

Desired Licensing:

• Active clinical license, e.g. nursing, physical therapy, LICSW
• Certified Professional Coder (CPC)

Required Experience:

• Minimum of 2 years' clinical experience
• Minimum 3 years' experience in the health care delivery system/industry or public health/public policy sector
• 1-3 years' supervisory or managerial experience

Required Knowledge, Skills & Abilities:

• Demonstrated competence with policy research and development within a healthplan, government agency, regulatory or accreditation body
• Must have effective verbal and written communication skills and demonstrate the ability to work well within a team.
• Demonstrated ability to deliver highly technical information to less technical individuals.
• Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.
• Proven time management skills are necessary. Must demonstrate the ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required. Demonstrated ability to work in a production focused environment.
• Proven ability to exercise sound judgment and strong problem solving skills.
• Proven ability to ask probing questions and obtain thorough and relevant information.
• Must be client service focused with effective ability to empathize.
• Must be proficient in the use of PC and various claim systems
• Must be proficient in the use of computers, specifically Microsoft Office products. Must have proven ability to learn new systems and databases that CCA implements.
• Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.

Desired Knowledge, Skills & Abilities:

• Policy brief development
• Policy Analysis
• Data analysis
• Power point, excel and word proficiency
• Medical Billing and Coding Certification

Language(s):

• English