Medical Policy Program Manager

Position Summary:

The Medical Policy Program Manager is primarily responsible to research, analyze, develop, and disseminate 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 program 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 Policy and other company subject matter experts. The program 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 program manager participates in 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:

• No

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.
• 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.
• Participate in 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.
• Lead and 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.
• 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.
• Collaborate with other departments regarding provider manuals and internal training materials to ensure materials are consistent with policies and state and federal guidelines.
• Understand medical policy decisions' impact on Member, Provider, Regulator, and Contractual documentations/communications.
• Represent Medical Policy team at cross-functional and inter-disciplinary meetings and on organizational project teams, and frequently interact with subordinate Supervisors, and/or functional peer group managers.

Working Conditions:

• Standard office conditions-fully remote

Required Education:

• Bachelor's degree from an accredited college or university required (degree in nursing or a health-related field

Desired Education:

• Master's 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)
• Medical Billing and Coding Certification

Required Experience:

• Minimum of 2 years' clinical experience
• Minimum 2 years' experience in the health care delivery system/industry or public health/public policy sector
• Experience managing cross-functional projects and/or programs

Required Knowledge, Skills & Abilities:

• Demonstrated competence with policy research and development within a Healthplan, government agency, regulatory or accreditation body
• Effective verbal and written communication skills and demonstrate the ability to work well within a team.
• Demonstrated ability to deliver highly specialized information to less technical individuals.
• Demonstrated professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.
• Proven time management skills: demonstrating 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.
• Proficiency in the use of computers, specifically Microsoft Office products. Must have proven ability to learn new systems and databases that CCA implements.
• Flexibility and creativity with developing working relationships with internal and external partners
• Ability to identify system problems and creatively facilitate processes to come up with solutions.
• Excellent writing and editing skills, and strong attention to detail.
• Demonstrated ability to readily master new business and health care content and employ the subject matter expertise in managing project content and staff.
• Strong leadership and organizational skills.
• Superb interpersonal and communication skills.

Desired Knowledge, Skills & Abilities:

• Policy brief development
• Policy Analysis
• Data analysis
• Power point, excel and word proficiency

Language(s):

• English