Medical Policy Nurse – First Coast Service Options

SUMMARY STATEMENT
This position is responsible for the development and maintenance of Local Coverage Determinations (LCDs) and Local Coverage Articles (Articles) in accordance with the CMS regulations and requirements and has a direct impact in ensuring access to care for Medicare beneficiaries, ensuring claims are paid correctly, and in safeguarding the Medicare trust fund.

 

 

ESSENTIAL RESPONSIBILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.

Development and Maintenance of LCDs and Articles: (80%)
* Working in close collaboration with the Contractor Medical Directors and other members of the Medical Affairs team, responsible for the timely and accurate creation and revision of LCDs and Articles in accordance with CMS regulatory guidance and requirements, especially those found in the Medicare Program Integrity Manual Chapter 13, to include all the following:
o Development and maintenance of new LCDs and Articles, including thorough review, analysis, and summary of the following:
 claims data,
 pertinent CMS instruction,
 available evidence, including but not limited to published medical literature, discussion with Contractor Advisory Committee (CAC) members, subject matters experts (SMEs), Medicare providers etc.,
 correct coding and billing requirements
o Review of Reconsideration Requests and completion of appropriate resulting LCD revisions
o Annual and other mandatory updates (e.g., diagnosis and procedure codes, Change Requests, etc.)
o Development and maintenance of accessible electronic LCD and Article files
o Participation in the formal, external Open Meetings and CAC meetings including creation and presentation of information specific to assigned LCDs
o Review and revision of departmental procedures related to LCD development and revisions.

Subject Matter Expert (SME): (20%)
* Serves as point of contact for internal operations regarding medical coverage and coding questions.
* Collaborates with edit team to ensure appropriate edits are created in keeping with the LCD instruction.
* Serves as SME for assigned LCDs and Articles and interfaces with technical, professional, and clinical personnel; routinely interacting with all levels of staff in the company, including the Executive Medical Directors, as well as other senior leaders.
* Attends regularly scheduled internal meetings to ensure adequate information sharing and education as appropriate throughout the company regarding LCDs and Articles.
* Accountable for regular and ongoing communication with external customers, including but not limited to, CMS, local and national medical societies/associations, stakeholders, other professional organizations, and Medicare providers, to ensure adequate information sharing and education regarding LCDs and Articles.
* Routinely and proactively collaborates with team members including the CMDs, senior leadership, and operational leads as necessary to identify and implement improvements related to the policy development process.

Performs other duties as the supervisor may, from time to time, deem necessary.

 

REQUIRED QUALIFICATIONS
* High School Diploma or GED
* 3 years’ related work experience; this includes 2 years of Medicare experience and 1 year of health insurance coding (e.g., ICD-10, CPT/HCPCS) experience
* Proficient in research of the CMS Internet-Only manual (IOM) and national and local coverage decisions
* Proficient in MS Office applications and Internet research
* Comprehensive knowledge of medical, surgical and diagnostic procedures and terminology
* Excellent written and oral communication skills
* Ability to communicate with confidence with other medical professionals, Medical Societies, Medicare providers, CMS and Contractor Advisory Committee (CAC) members
* Professional demeanor and positive approach to work
* Excellent planning, organizing, time and work management skills
* Ability to travel

CERTIFICATIONS, LICENSES, REGISTRATIONS
* Valid unrestricted Registered Nurse (RN) license

 

 

PREFERRED QUALIFICATIONS
* Bachelor’s degree in Nursing
* 5 or more years of clinical experience as a Registered Nurse
* 3 or more years of Medicare experience
* 3 or more years of experience in Health or Business Administration
* 3 or more years of health insurance experience in operations, claims review, case review, education, and/or medical and payment policy
* 3 or more years of health insurance coding (e.g. ICD-10-CM, CPT/HCPCS)
* Certified Professional Coder (CPC) certification/credential

Background Investigation: If you are selected for this position, you must undergo a pre-employment Background Investigation, Drug Screen, and Identity Proofing documentation must be cleared prior to hire. Most positions are subject to additional Identity Proofing, Fingerprinting and additional Background Investigation screening conducted by the Federal Government to be granted Enterprise User Administration (EUA) system logical access after you begin your employment. Your continued employment is contingent upon the outcome of the complete additional screening criteria required for the position which must find that you meet the applicable government customer’s requirements (e.g., suitable for access to CMS information and information systems), as well as any additional investigation which may be required throughout your employment. If you are found not suitable, your employment may be subject to corrective action, up to and including immediate termination of employment.

 

Identity Documentation: You must have access to a current and unrestricted REAL ID, U.S. Passport, U.S. Passport Card, Foreign Passport, or U.S. Permanent Residency Documents. Note: Employment Authorization Cards (EAD) are not a substitute for Visas or U.S. Permanent Resident Cards.